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Congenital Adrenal Hyperplasia

- Cortisol deficiency - Increased androgens --> ambiguous genitalia, virilization, precocious puberty - Hyponatremia - Hyperkalemia --> metabolic acidosis

Conn Syndrome (Primary aldosteronism)

- Hypertension - Hypokalemia - metabolic alkalosis - Hypernatremia - Hypomagnesemia - Muscle weakness - Decreased serum renin - Albuminuria

Addison Disease (Adrenal Insufficiency)

- Hypotension - Hyperpigmentation - Hypoglycemia - Diarrhea

A 22-year-old male presents to the clinic with the complaint of episodic anxiety. The history reveals these symptoms began suddenly 3 months ago and each episode lasts about an hour, with the last episode being a week ago. In between episodes, he feels no anxiety. The episodes begin with a headache and a racing heart followed by diaphoresis. He denies any sense of worry or obvious triggers. Medical history reveals a thyroidectomy due to a benign thyroid adenoma, after which he has taken levothyroxine. His vital signs reveal a blood pressure of 162/98 mmHg, a heart rate of 108/min, and a body mass index of 22 kg/m2. He is an otherwise well-appearing male with a normal sounding heart and lung exam. Lab work demonstrates a normal complete blood count, basic metabolic panel, and hemoglobin A1c. His thyroid stimulating hormone demonstrates that he is currently euthyroid on his medications. Given his symptoms and normal laboratory values, which of the following is the most appropriate next step to confirm a possible diagnosis

24 hour urine metanephrines - Pheochromocytoma These are catecholamine-secreting tumors which arise from chromaffin cells of the adrenal medulla. Pheochromocytomas present with episodic headache, hypertension, diaphoresis, tachycardia, anxiety, and chest pain. They can often be mistaken for panic attacks and patients will often have a completely normal exam if they present when they are asymptomatic. They are best diagnosed by elevated metanephrines and catecholamines in a 24-hour urine. If urine testing is positive, the patient must then undergo imaging of the abdomen and pelvis to locate the tumor which can be extra-adrenal, but are mostly within the abdomen and pelvis. While most pheochromocytomas are sporadic, they are also associated with several genetic syndromes. -Von Hippel-Lindau syndrome -Multiple endocrine neoplasia type 2 (MEN2) -rarely Neurofibromatosis type 1 Classically, pheochromocytomas are found in approximately 50% of patients with MEN2A.

A 43-year-old male presents to your clinic complaining of polyuria including nocturia and polydipsia. Upon further questioning, he states that he also has noticed blurred vision and some weight fluctuation. He tells you that he gets very little exercise and eats a poor diet with large portion sizes and very few fruits and vegetables. Physical examination is significant for obesity, a "dirty" appearance to his posterior neck, and a posterior Chapman reflex point located at the right T7 intertransverse space. You are concerned that he has developed diabetes and obtain a fasting glucose that returns at 190 mg/dL. You retest test him again 2 weeks later, and the results indicate that his A1C is 8.6%. Which of the following is the most appropriate A1C goal for this patient?

< 7.0% Although there is disagreement among medical societies on the most appropriate A1C goals, the American Diabetes Association (ADA) is most often used for testing purposes. According to the 2018 ADA guidelines, the A1C goal for patients with diabetes is < 7.0%.

Surface antigen positive E-antigen positive Core antibody positive IgM Surface antibody negative

Acute infection Hepatitis B surface antigen and e-antigen rise and fall early in the course of infection (between 8 and 20 weeks for the surface antigen and 8 and 24 weeks for the e-antigen). The core antibody begins to rise at around 12 weeks and can remain positive. It is IgM during the acute phase and transitions to IgG when chronic or resolved. The surface antibody begins to rise later in the course and is positive in vaccinated individuals and in resolved infections.

An 81-year-old male is brought in by his family with complaints of worsening memory loss and forgetfulness. His family notes a gradual decline in function over the last several months. History reveals that he was recently returned home by police because he had gotten lost driving. His family reports that he has also been acting much more paranoid than usual. Last week he accused his son of stealing all of his money. Past medical history is significant for type II diabetes, hypertension and hyperlipidemia. Vital signs reveal a temperature of 98.7 F, a blood pressure of 143/86 mmHg, a heart rate of 71/min, a respiratory rate of 16/min, and an oxygen saturation of 100% on room air. Physical examination reveals grossly intact cranial nerves and no focal deficits. He is oriented to person and place but not time. Mini-mental status examination reveals a score of 17/30. He denies hallucinations, tremors, or rigidity.

Alzheimers Disease Neurodegenerative disease and is the most common cause of dementia. Approximately 50 percent of patients with dementia have AD. Prevalence increases with age; autopsy studies have shown that AD changes can be seen in most individuals as they age. AD is a chronic disease with latent and prodromal stages. Memory loss is the presenting symptom. Visuospatial disturbances, poor concentration and impaired judgment are also observed. AD is a clinical diagnosis. Progressive atrophy, gliosis and diffuse cortical atrophy with enlargement of the ventricles can be seen on neuroimaging. Histopathology shows senile plaques which are characterized by eosinophilia and amyloid A beta deposition. The hippocampus is primarily affected. Neurofibrillary tangles which are intraneuronal aggregates of abnormally modified microtubule associated tau proteins are also characteristic.

A 13-year-old male presents to the office with the complaint of an intensely itchy rash on his elbows and knees. History reveals the rash began as small vesicles. Family history reveals the mother has Grave disease. Physical examination reveals excoriated papules and erosions that are crusted over on extensor surfaces including the elbows, knees and also buttocks. Image of the rash is shown in the exhibit. The most appropriate test to confirm the diagnosis is

Anti-endomysium antibody Dermatitis herpetiformis, which is associated with celiac disease. Dermatitis herpetiformis characteristically presents as an intensely itchy rash on the extensor surfaces with multiple excoriations. This rash is not common in children, but it can occur and further work-up is warranted. Family history of Grave disease gives some clue that an autoimmune process may be involved. Serologic testing may be performed to look for anti-gliadin, anti-tissue transglutaminase, or anti-endomysium antibody. Immunofluorescence would demonstrate the deposition of IgA in the papillary dermis.

A 45-year-old male presents to the office for results of blood work. History reveals depression of two years' duration, progressively worsening forgetfulness, and choreiform movements for two months' duration. Family history reveals a father who passed at 45-years-old of a "progressive dementia illness." Vital signs reveal a temperature of 98.7 F, a blood pressure of 128/74 mmHg, a heart rate of 65/min, a respiratory rate of 18/min and an oxygen saturation of 100%. Physical examination reveals a well-developed male in no acute distress with occasional choreiform movements. A recent computed tomography scan of the brain reveals bilateral caudate atrophy. Genetic testing reveals increased detection of trinucleotide CAG expansion in HTT gene by polymerase chain reaction. His 23-year-old son recently married and is planning on having children of his own. He asks if his children will inherit the disease similarly. The inheritance pattern can be explained by

Anticipation - Autosomal Dominant Huntington disease (HD) which is an incurable, adult-onset, autosomal dominant inherited disorder associated with cell loss within a specific subset of neurons in the basal ganglia and cortex. Gross atrophy of the caudate nucleus and putamen is accompanied by selective neuronal loss and astrogliosis. Characteristic features of HD include involuntary movements, dementia, and behavioral changes. Atrophy in the caudate and putamen may be seen on CT scan or MRI. Diagnosis is made by detection of trinucleotide CAG repeating in HTT gene by polymerase chain reaction or Southern blot. Anticipation is when the genetic disorder becomes apparent at an earlier age. This is common in HD as the parent may pass on the CAG repeats to his or her offspring and during DNA replication the offspring creates more repeats. This patient should be counseled that if he has HD he may see signs at an earlier age than his father. If he and his wife elect to have children their children may show signs of the disease at an even earlier age (provided they inherit HD).

A 27-year-old man presents to the outpatient clinic with a complaint of discharge from his penis. He states that he has sexual contact with multiple partners over the past few weeks and has never used condoms. He is also sexually active with his girlfriend of 5 years. He first noticed the discharge two weeks ago and become concerned when he looked up his symptoms on the internet and now is concerned that he may have a sexually transmitted disease (STD). He undergoes testing which comes back positive for Gonorrhea. In addition to treating his symptoms, what else would need to be done for this patient?

Ask the patient to practice safe sex, use condoms, and inform his sexual partners they may have been exposed to an STD and need to get tested.

A 60-year-old male with a history of hypertension and coronary artery disease presents to his primary care physician because of progressive loss of balance. Review of the patient's history also reveals a penicillin allergy. He still feels unsteady on his feet and is concerned for his safety at home since he lives alone. He also occasionally gets sharp, shooting pain in his legs. He denies headache, dizziness, nausea, vomiting, visual difficulty, or recent head injury. Examination reveals a left pupil that is unresponsive to light but contracts normally with convergence. Lower extremity reflexes are absent. Vibration and position sense are impaired in the lower extremities. His gait is high-stepping, and his feet slap the floor when he walks. Cardiac auscultation reveals a 2/6 diastolic murmur. The remainder of the examination is unremarkable. Cerebrospinal fluid (CSF) pressure is normal when lumbar puncture is performed. A sample is sent to the laboratory for serology and the results provide a definitive diagnosis. Which of the following is the most appropriate next step?

Begin penicillin desensitization and report the CSF results to state health department only Neurosyphilis and needs immediate treatment with penicillin. In penicillin allergic patients desensitization is performed to allow the administration of penicillin. Syphilis is one of several "reportable illnesses" which must be reported to the state health department, with or without the patient's consent. In most states hepatitis A and B, Salmonella, Shigella, measles, mumps, AIDS, rubella, tuberculosis, Chlamydia, varicella, and gonorrhea are also reportable.

A 58-year-old male presents to the office with the complaint of right shoulder pain. He states that he noticed the pain several months ago and thinks it is progressing. The pain is 6/10 and is worse when reaching over his head and better with rest. Physical examination of the right upper extremity reveals no visible deformities with full active and passive range of motion. There are strong pulses and 5/5 muscle strength throughout the extremity. The most tender spot to palpation is on the anterior aspect of the shoulder. The patient's pain is exacerbated when you have him supinate his forearm against resistance. The most likely diagnosis is

Bicipital tendonitis Bicipital tendonitis presents with anterior shoulder pain, worst near the bicipital groove. Pain may be exacerbated with supination and/or flexion of the elbow. Yergason's and Speed's tests may be positive. It is initially treated with conservative treatment including rest, activity modification, physical therapy and oral NSAIDs. When conservative treatments fail to relieve the patient's pain, corticosteroid injection into the bicipital groove is indicated. When all previous treatments fail, a biceps tenodesis or biceps tenotomy is indicated

A 28-year-old male presents to the office after returning home from a 2-week hiking trip to Vermont. He states the weather was very warm and that they were lucky to spend each day outside on the trails. After arriving home, he was feeling tired and had a headache, fever, muscle aches, loss of appetite, and neck stiffness. He went to an urgent care facility, where he was diagnosed with a viral upper respiratory tract infection. He is coming to see you, though, because he doubts the diagnosis, given that he does not have any respiratory symptoms. Although he has used some over the counter therapies without relief, he reports that NSAIDs do ease some of his discomfort. Other than the presence of mild inguinal lymphadenopathy, his physical exam is normal without any rash. Which of the following is the most likely cause of his symptoms?

Borrelia burgdorferi Lyme disease is the most common vector-borne disease in North America. It is caused by the spirochete Borrelia burgdorferi, which is commonly carried by Ixodes ticks on white-tailed deer and white-footed mice. Lyme disease is most commonly seen during the summer months in the northeast, northern Midwest, and Pacific coast. It classically presents with fever, malaise, headaches, myalgias, arthritis, and erythema migrans. Erythema migrans is a rash (seen in picture below) that begins as a small erythematous macule and is found at the tick-feeding site; it occurs in about 80% of patients with Lyme disease. This site expands slowly over days to weeks and forms a raised border with a central clearing, classically described as a "bull's-eye" appearance. This patient has the classic symptoms of Lyme disease and was in an endemic area. He does not have the erythema migrans rash; however, 20% of patients with Lyme disease do not have this rash. Lyme disease is treated with doxycycline, amoxicillin, or cefuroxime.

A 68-year-old male with hypertension on furosemide presents with widespread blistering over his flexor surfaces, abdomen, and perianal regions. The blisters are tense and demonstrate a positive Absoe-Hansen sign. Nikolsky's sign is absent. Immunofluorescence demonstrates antibodies to the basement membrane.

Bullous pemphigoid Bullous disorder of autoimmune origin, characterized by autoantibodies to the epidermal basement membrane, specifically bullous pemphigoid antigen 2. Most patients are over 60 years of age and present with widespread blistering, most prominent over the flexor surfaces and perineal region, but can also involve the abdomen and thighs. In the early phases, patients may present with itchy urticarial lesions that evolve into tense blisters. Due to their tense nature, the Absoe-Hansen sign, which involves placing pressure directly over the blister, will cause it to spread. The Nikolsky sign is positive in pemphigus vulgaris but not bullous pemphigoid. Look for the presence of anti-basement membrane antibodies demonstrated by immunofluorescence.

A 45-year-old female with a predominant psychiatric history on multiple medications presents to the office due to a tremor. History reveals that the tremor has been ongoing for approximately 2 years, and she notices it in both hands. It is slow and steady and only occurs when her hands are at rest. She does not think that the tremor has gotten worse since it started. On examination, she is very slow when she attempts to do rapid alternating movements, has cogwheel rigidity, and a slow shuffling gait. Which of the following is the most appropriate next step in management?

Carefully review her medication list Patient has parkinsonism, which is characterized by bradykinesia, rigidity, and tremor. There are many disease states that can present with parkinsonism that need to be eliminated before a diagnosis of Parkinson disease can be made, especially in a young patient. The most common is drug-induced parkinsonism. Medications such as haloperidol, fluphenazine, and other dopamine-blocking medications, including other antipsychotics, are common culprits. Other causes include the so-called Parkinson-plus syndromes such as corticobasal degeneration, Lewy body dementia, progressive supranuclear palsy, and multiple systems atrophy. Parkinsonism due to repeated infarcts of the basal ganglia ("vascular parkinsonism") and normal pressure hydrocephalus are other causes. This patient has some atypical features that should make her clinician consider other causes of parkinsonism besides Parkinson disease: She is younger than 60 years of age, her tremor is bilateral, and it is nonprogressive. Her medication list should be reviewed for neuroleptic medications.

An 83-year-old patient develops an abnormal breathing pattern while asleep in a nursing home. Past medical history reveals congestive heart failure. The pattern consists of a repeated cycle of apnea followed by hyperpnea. The hyperpnea demonstrates a waxing-waning pattern of tidal volume. This is a description of which of the following respiratory patterns?

Cheyne-Stokes respirations Cheyne-Stokes respirations describe an abnormal breathing pattern characterized by cycles of apnea followed by hyperpnea. This occurs as the body's way of compensating for changing serum partial pressures of oxygen and carbon dioxide. Congestive heart failure, which is noted in the above patient's history, has a strong association with this breathing pattern. Cheyne-Stokes respirations can also be seen in patients with brain stem injury. It is also seen in the case of central sleep apnea.

A 20-year-old female presents to your office with the complaint of malaise. She states that, for the past several months, she has felt very tired all the time. Review of systems is positive for sleep disturbance and intermittent varying joint pains. She believes her symptoms began following cold-type symptoms. Her fatigue gets much worse with exercise. She is otherwise healthy, with no past medical history. Her Patient Health Questionnaire score is 0. She denies any substance abuse, and rarely, if ever, drinks alcohol. She does not take any medications. Her vital signs are normal and her BMI is 22. Her physical exam reveals normal HEENT findings without tonsilar hypertrophy. Her joints do not have any evidence of synovitis and her muscle strength is full. You order labs, specifically a CBC, complete metabolic panel, TSH, Epstein-Barr Virus test, C-reactive protein, and creatinine kinase; all are normal. Given this patient's history and findings, which of the following is the most likely diagnosis?

Chronic Fatigue Syndrome Young to middle-aged adults and is more common in women. There are many proposed etiologies, including viral, immune, endocrine-metabolic dysfunction, and neuropsychiatric. Certain common clinical features of CFS are important to recognize. For example, fatigue symptoms are often sudden in onset and can begin after an infection, such as an upper respiratory tract infection; in some patients, though, onset is gradual. In addition, patients experience significant or overwhelming fatigue, often associated with altered cognition or sleep. These symptoms are made worse by physical activity.

A 16-year-old female presents to the office with the complaint of decreased sensation along the right leg. History reveals the symptoms have been worsening since receiving a blow to the lateral knee during a soccer game. Physical examination reveals normal capillary refill in the lower extremities, hypoesthesia in the right anterolateral leg, and +4/5 muscle strength with dorsiflexion of the right foot. You notice that she holds her right leg in slight external rotation relative to the left, and there is tenderness to palpation of the lateral head of the right gastrocnemius muscle. You also note paravertebral spasms from T11-L2 that are tender to palpation. The patients symptoms are due to injury to the

Common peroneal nerve Presence of TART changes from T11-L2 representative of a viscerosomatic reflex from the lower extremity. The sciatic nerve gives rise to both the tibial nerve and the common peroneal nerve in the popliteal fossa. Common peroneal nerve supplies sensation to the anterolateral leg and motor innervation to the anterior lower leg. In the proximal lateral compartment of the leg it bifurcates into the deep and superficial peroneal (fibular) nerves. Superficial peroneal nerve remains in the lateral compartment while the deep pierces the anterior intermuscular septum and descends into the extensor compartment. The superficial peroneal nerve supplies motor innervation to the fibularis longus/ brevis and sensory to the medial/intermediate dorsal cutaneous nerves. Deep peroneal nerve supplies the tibialis anterior, extensor digitorum longus/brevis, extensor hallucis longus/brevis and fibularis tertius.

A 50-year-old male presents to the office with a 3-month history of headaches and muscle weakness. He has also been urinating frequently during this period. Vital signs reveal a blood pressure of 165/105 mmHg. Laboratory studies reveal hypokalemia, hypernatremia, metabolic alkalosis, and decreased serum renin concentration. Urinalysis reveals albuminuria. Which of the following is the most likely diagnosis?

Conn Syndrome Overproduction of aldosterone and is most commonly caused by aldosterone-producing adenomas. Excess aldosterone causes the distal tubules in the nephrons to retain sodium (hypernatremia) and excrete both potassium (hypokalemia) and hydrogen ions (alkalosis). This leads to hypernatremia, hypokalemia, and metabolic alkalosis

A 51-year-old female presents to the office complaining of hot flashes, mood changes, and decreased libido. She is otherwise healthy and does not take any medications. These symptoms began about 6 months ago but have recently worsened and are concerning her. Vital signs are within normal limits. Physical examination does not reveal any significant findings. A recent DEXA scan indicates a T-score of 2.7 standard deviations below the mean. Which of the following is associated with the most likely diagnosis?

Decreased estrogen, increased FSH, increased LH, increased GnRH

A 76-year-old male presents to the office with the complaint of fatigue and weakness. On review of symptoms, the patient admits to dark-colored stools and cravings to eat ice throughout the day. Physical examination reveals generalized pallor, pale conjunctiva, and irritation of the corners of his mouth. Which of the following laboratory changes would most likely be seen in this patient?

Decreased ferritin, decreased iron, increased transferrin Iron deficiency anemia is the most common cause of anemia worldwide. Iron is a vital metal for living organisms. It is used in oxygen transport, deoxyribonucleic acid (DNA) synthesis, and electron transport. Iron is absorbed by the proximal small intestine and is delivered to cells via transferrin. Ferritin is the primary iron storage protein of the cells and is low when iron stores are low. Iron deficiency anemia is caused by insufficient dietary intake, iron malabsorption, and/or iron loss from bleeding. In females, blood loss from menstrual bleeding must always be excluded. This patient most likely has iron deficiency anemia due to gastrointestinal bleeding secondary to malignancy. Clinical features include pallor, fatigue, weakness, dyspnea on exertion, orthostatic hypotension, and/or tachycardia. Laboratory analysis in iron deficiency anemia reveal a high red blood cell distribution width (RDW) with a low mean corpuscular volume (MCV); microcytic anemia. Serum iron may be normal early, but by the time patients are symptomatic, a low serum iron is often evident. Given iron is low, the iron storage protein ferritin is low as well. A low serum ferritin is the most sensitive lab test for iron deficiency anemia. Transferrin, which transports iron from the intestines to red blood cells, becomes elevated as the liver produces more transferrin in an effort to bring more iron to the iron hungry cells. Total iron binding capacity measures the capacity of transferrin to bind iron and given iron is low, there is plenty of room for iron to bind. A low serum iron and ferritin with an elevated transferrin and total iron binding capacity (TIBC) are laboratory values seen in iron deficiency anemia.

A 40-year-old male with a past medical history of tobacco abuse, hypertension, and hyperlipidemia presents to his primary care office with the complaint of myalgias for the past 2 weeks. History reveals myalgias in the bilateral thighs and upper arms. He denies any recent trauma or changes in physical activity to which his symptoms may be attributed. He denies any weakness or paresthesias. Medications include lisinopril 20 mg daily and simvastatin 20 mg daily, both of which were started 2 months prior. His physical examination is unremarkable. Labs include a normal basal metabolic panel, with a CPK mildly elevated at 140 mcg/L (reference range 15-105 mcg/L). What is the best management approach for this patient's condition and long-term health?

Discontinue Simvastatin; begin therapy with another statin when pain resolves Statin-induced myopathy - Avoid taking fibrates concurrently with statins - Check for drug interactions and modify therapy to minimize risk - Change to a better-tolerated statin such as including fluvastatin or pravastatin - If different statins are still not tolerated, consider alternative dosing schedules, such as every other day or reduced dosing - Check for Vitamin D deficiency and hypothyroidism, as these have been correlated with increased myopathy risk

A 65-year-old female presents to the office for an annual examination. She has no complaints at this time and feels generally well. Her medical history is significant for hypertension, a remote history of breast cancer that was treated with mastectomy, and a hip fracture that occurred 2 years ago. She has a 25-pack-year smoking history but has been tobacco free for over 15 years. Her medications include lisinopril and a baby aspirin daily. She does not exercise regularly. Vital signs reveal a temperature of 37.0°C (98.6°F), a heart rate of 71/min, a respiratory rate of 13/min, a blood pressure of 126/82 mmHg, and a body mass index (BMI) of 19.3 kg/m2. Physical examination is unremarkable. The most appropriate preventive screening test is

Dual energy x-ray absorptiometry DEXA scan typically measures BMD at the hip or lumbar spine. The United States Preventive Services Task Force recommends routine screening for women over the age of 65. How often to repeat the DXA scan depends on the initial findings. For women with a T-score of −2.0 to −2.49, repeat testing should be performed in 2 years. For women with a T-score of −1.50 to −1.99, repeat testing should be performed in 3 to 5 years. For women with a normal bone density, repeat testing can be performed at 10 to 15 years.

A 20-year-old male college student presents to the office with the complaint of fever and sore throat and fatigue for 3 days' duration. Physical examination reveals tender tonsillar exudates, bilateral tender posterior cervical lymphadenopathy, and splenomegaly. Complete blood count reveals a reactive (atypical) lymphocytosis without thrombocytopenia or anemia. The most likely diagnosis and confirmatory test is

Epstein-Barr viral infection with heterophile antibody test The most likely diagnosis is infectious mononucleosis. The most common cause is Epstein-Bar virus (EBV) infection, which is prevalent among college students. It causes generalized lymphadenopathy more often posterior than anterior, exudative tonsillitis, palatal petechiae, and may cause splenomegaly. A heterophile antibody test is positive in these patients and is about 85%-100% sensitive. If the heterophile antibody test is positive, no further workup or testing is necessary. The test can occasionally be falsely negative in the early period of the illness (7-10 days). In this case, you would repeat the test in 1-2 weeks or perform specific antibody testing. Transient thrombocytopenia MAY be seen in EBV infectious mononucleosis. Severe or persistent thrombocytopenia should suggest an alternate diagnosis (eg, acute HIV or other viral infectious diseases). Thrombocytosis is not a feature of EBV infectious mononucleosis, and its presence should suggest an alternate diagnosis such as malignancy due to lymphoma in adults, or Kawasaki disease in children. Patients with splenomegaly are at risk for splenic rupture and should avoid contact sports until the spleen resumes a normal size.

This type of hepatitis is spread through contaminated food and the fecal-oral route and is more common than other types of hepatitis in the United States. This type of hepatitis only causes acute disease and a vaccination is given when traveling to a developing nation.

Hepatitis A Picornavirus most commonly spread through food, like shellfish. This type of hepatitis is prevented by giving a vaccine before traveling to developing countries. HAV can cause food-borne outbreaks in the U.S., usually associated with infected food handlers in restaurants. Most commonly, this is self-limiting, and may only require supportive care.

A 56-year-old male with a past medical history of hypertension and Type 2 diabetes mellitus presents to the office with the complaint of an "itchy rash" of four months duration. He states the rash first developed in his left armpit, but it has since spread to his right armpit, abdomen, and groin. The rash is a little pruritic, but he is mostly concerned with the change in color and the fact that it has been spreading. He notes he did have eczema as a child and exercise induced asthma, but has not had any rashes or problems with asthma since adolescence. Vital signs are all normal and he is afebrile. Physical examination reveals an obese male with well demarcated erythematous patches showing some brown discoloration and fine, macerated scale involving bilateral axillae, inguinal folds, between some of his toes, and under each abdominal pannus. Several KOH preparations of skin scrapings from his left foot, groin, and underarm are negative for dermatophytes. Wood lamp examination is performed as shown in the exhibit.

Erythrasma Erythrasma is an infection of the superficial layer of the skin by Corynebacterium minutissimum, considered to be normal skin flora. It typically presents as scaly plaques between the toes, but it can manifest as brown patches or plaques in intertriginous areas, including the axillae, groin, and inframammary regions. Most cases are asymptomatic, but it can be mildly pruritic. Diabetics and immunocompromised patients are at a higher risk for this infection, especially with intertriginous manifestation. Gram-stain of the patches show gram-positive rods, but the diagnostic test of choice is the use of Wood lamp, which demonstrates coral-red fluorescence. This is due to the porphyrins that are produced by the bacteria. Treatment: Oral erythromycin

Thompson test

Evaluates for the presence of a completely ruptured achilles tendon. To perform the test, the patient is typically placed prone with the feet hanging over the end of the table. The affected calf is then squeezed, thereby shortening the musculotendinous unit of the gastrocnemius and the soleus muscles. This places tension on the Achilles tendon, causing plantarflexion. If the Achilles tendon is completely torn, squeezing the calf does not produce plantarflexion, indicating a positive test. In some instances, a partial tear may occur and the Thompson test may be negative since some of the tendon is still intact.

A 65-year-old female with a past medical history of achalasia presents to the office for a routine follow-up appointment. History reveals she has been experiencing hot flashes and vaginal dryness since she started menopause at age 58. Her family history is significant for her mother who died of breast cancer at age 53. A dual energy x-ray absorptiometry scan is obtained and reveals a T-score of -2.7. The most likely side effect of treating this patient with raloxifene is

Exacerbation of postmenopausal symptoms Raloxifene acts as an estrogen receptor antagonist in breast, endometrial, and vaginal tissues. Although these antagonistic effects are beneficial in preventing endometrial and breast carcinoma, they may worsen menopausal symptoms like hot flashes and vaginal dryness. T-score Interpretation +1 to -1 Normal bone density -1 to -2.5 Osteopenia < -2.5 Osteoporosis

A 28-year-old male presents to the office with the complaint of right-sided knee pain. History reveals that the patient is a long distance runner and frequently experiences pain under his right kneecap that becomes more intense following prolonged sitting. He also has difficulty climbing and descending stairs due to the pain. Vital signs are a temperature of 37° C (98.6° F), blood pressure of 119/81 mmHg, heart rate of 61/min, respiratory rate of 16/min, and an oxygen saturation of 100% on room air. Physical examination reveals no visible swelling. He has a full range of motion in flexion and extension, and 5/5 muscle strength of the lower extremities bilaterally. There is positive 2 point discrimination. He has significant pain during patellar compression and crepitus during extension, and the patella tracks laterally during active extension. A Lachman test and posterior drawer test are negative. The most appropriate next step in management is

Exercise and Physical therapy Patellofemoral pain syndrome, also known as runner's knee, refers to anterior knee pain that worsens while going up or down stairs, walking hills, or with prolonged sitting with knees flexed (theater sign). Another indicator of patellofemoral pain syndrome is the J-sign, which is present in this case and is positive when the patella tracks laterally during terminal knee extension. Patellofemoral syndrome is associated with weakness of the vastus medialis. Radiographs, if ordered, are usually normal. Treatment is best achieved by recommending a change of training with special attention to strengthening the vastus medialis. Remember that the vastus medialis is located medially to the knee, and when the vastus lateralis becomes more powerful, the result is the lateral patellar tracking during knee extension.

A 27-year-old female presents to the office with the complaint of right elbow pain that has gotten worse during the past 3 weeks. She has no past medical history and denies ever having surgery. She takes oral contraceptive pills for birth control, denies smoking, and admits to social alcohol use. The patient's family history is unknown as she is adopted. She works as a receptionist for an office. She states that she started playing racquetball 4 weeks ago in an attempt to get in shape. Physical examination reveals pain that is reproducible with supination of the forearm, resisted wrist extension, and point tenderness at the lateral epicondyle. The patient's symptoms are most likely due to microscopic tearing of

Extensor carpi radialis brevis Lateral epicondylitis, also known as tennis elbow. Lateral epicondylitis is an overuse injury common among amateur tennis or racquetball players using improper technique when hitting strokes from the backhand side. It also occurs secondary to any activity that involves repeated supination of the forearm, such as using a screwdriver. This condition occurs as a result of microscopic tearing that takes place at the origin of the extensor carpi radialis brevis and presents with pain at the lateral aspect of the elbow. It can also involve other wrist extensors, but the extensor carpi radialis brevis is the most commonly involved. Classic examination findings include tenderness at the lateral epicondyle and pain with extension of wrist against resistance.

A 39-year-old female presents with crusting and flaccid vesicles over erythematous plaques involving the groin, axillae, and lateral neck. She reports burning and pruritus during the outbreak, which can be brought on by humid hot weather. She also reports a foul odor from these areas. One of her parents has the same condition.

Familial benign pemphigus (Hailey-Hailey disease) Autosomal dominant disease due to a mutation in ATP2C1, a calcium ATPase pump. It is characterized by the presence of vesicular lesions and crusting erythematous plaques over intertriginous areas including the genitals, inguinal area, sometimes extending onto the thigh, as well as the chest, neck, and axilla. Burning and pruritus accompany the eruption, as well as a malodorous drainage that may occur from secondary bacterial infections. Staphylococcal and Candidal spp. are typically cultured.

A 30-year-old female presents to the office with the complaint of a painful pruritic rash on her legs, elbows, and scalp. Physical examination reveals red plaques with silvery scales. She claims that she had a similar, but mild, rash eight months prior that resolved on its own. History also reveals associated fatigue with muscle aches and stiffness. Past medical history reveals she recovered from an episode of mononucleosis three weeks prior. The most useful further history to confirm the diagnosis includes

Family history of skin disease Psoriasis, which is characterized by pruritic, burning, and red plaques with silvery scales. The lesions generally occur on the extensor surfaces of the extremities. Associated symptoms include nail pitting and onycholysis, detachment of the nail from the nail bed. Classical physical examination findings include Auspitz sign and Koebner's phenomenon. Auspitz sign is characterized by bleeding when the scale is removed. Koebner's phenomenon is characterized by the appearance of new lesions at sites of physical trauma. One of the most significant risk factors is family history. Diagnosis is made clinically with tissue biopsy being the gold standard. Treatment includes topical steroids, PUVA (psoralens plus UV-A light), and methotrexate or cyclosporine.

Fibular head Nerve lies directly posterior to the proximal fibular head and supplies sensory innervation to the anterior lateral leg. A posterior fibular head somatic dysfunction or fracture of the fibula may cause dysfunction of this nerve. It may also be seen in patients that sit crossed legged for a prolonged period of time. When you have a posterior fibular head, the distal portion of the fibula moved anterior which causes slight internal rotation of the talus and therefor the foot. Because of this you will often see people compensate using hip external rotation to keep the feet aligned properly. In addition, posterior fibular head often results in gastrocnemius spasm as seen in this case.

Foot drop This patient has impingement of the common peroneal (fibular) nerve which provides sensory innervation to the anterior lower leg via the L4-S2 nerve roots. It also supplies motor innervation to muscles responsible for dorsiflexion of the foot, therefore dysfunction results in foot drop. If the impingement at the fibular head is not resolved her condition will most likely progress to foot drop.

A 54-year-old female presents to the office with a persistent cough for 5 months that is worse at night. She also experiences intermittent regurgitation with a "burning" sensation. She also describes having a metallic taste in her mouth. Her past medical history includes hypertension for which she receives ramipril daily. She does not drink any alcohol and has not for many years. Her physical examination is unremarkable. She denies any dysphagia, vomiting, weight loss, or loss of appetite. The most likely diagnosis is

Gastroesophageal reflux Gastroesophageal reflux (GERD) is a chronic syndrome characterized by gastric juice leaking into the esophagus. It is primarily caused by impaired tone (increased relaxation) of the lower esophageal sphincter. Other causes include decreased esophageal motility, gastric outlet obstruction, hiatal hernia, or diet. Items such as alcohol, tobacco, chocolate, coffee, and high-fat foods may decrease lower esophageal sphincter pressure. Risk factors include obesity, age, and consumption of a Western diet. Clinical features include heartburn, dyspepsia, and cough. Patients may report "water brash," a bitter, metallic taste in the mouth that is caused by an accumulation of saliva and gastric acid that has been regurgitated. Cough is a quite common presentation for GERD. In fact, in adults with new chronic cough, the top 3 causes are upper airway cough syndrome, asthma, and gastroesophageal reflux. In patients with classic symptoms, treatment can be initiated without further workup. In patients with alarm symptoms such as weight loss, vomiting, or anorexia or those with abnormal abdominal imaging, a basic workup including upper gastrointestinal endoscopy should be completed.

A 55-year-old female presents to the office for an annual physical. Her only complaint is back pain between her shoulder blades. She was recently diagnosed with type 2 diabetes at her last office visit one month ago. Past medical history reveals hypertension, hyperlipidemia, and iron deficiency anemia. You note paravertebral hypertonicity from T6-10 that is tender to palpation. Vital signs reveal a blood pressure of 138/88 mmHg and BMI of 25.7. Laboratory studies reveal: LDL 84 mg/dL HDL 56 mg/dL Triglycerides 104 mg/dL Hemoglobin A1C 8.1 % Hemoglobin 12.6 g/dL Hematocrit 36.1% MCV 93 fl The most important issue to address is

Glycemic control

A 58-year-old male presents with an intensely pruritic erythematous papular eruption on his back. He states that he was bed bound while hospitalized for the past 3 weeks. On history, he admits to a prior occurence a few years ago following a bout of intense sun exposure. Histopathology reveals focal acantholytic dyskeratosis.

Grover disease (transient acantholytic dermatosis) Benign, self-limited dermatologic condition that appears suddenly as an itchy papular rash over the trunk. Its etiology is unknown although it may be triggered by excessive sweating, heat, humidity, and sun exposure. It is often seen in middle aged to elderly men, although can occur in women. The rash of Grover disease can sometimes be seen on the backs of patients who have been hospitalized and bed bound for a prolonged period of time. The condition may self resolve, or may wax and wane over many years. The rash usually appears as small, pink or red papules on the central back or mid-chest regions. Histologic findings include focal acantholysis and dyskeratosis, which helps to distinguish it from the more widespread acantholysis of pemphigus vulgaris and lack of dyskeratosis in pemphigus vulgaris. Bullous pemphigoid will not show acantholysis of the epidermis but rather a separation at the level above the basement membrane.

This form of hepatitis uses a reverse transcriptase to replicate inside hepatocytes.

Hepatitis B Hepadnavirus that is spread through blood contact and other body fluids, including sexual contact. HBV is the only hepatitis virus that has DNA as the genome, and it also has a reverse transcriptase that it uses to make DNA from viral RNA in the cytoplasm. HBV can manifest as acute viral hepatitis or chronic symptoms including, cirrhosis or hepatocellular carcinoma. Treatment involves HBV vaccine in unvaccinated individuals, and IFN-α or antiviral drugs. A subunit vaccine containing the HB surface antigen is available.

This type of hepatitis is spread through blood, and coats itself with low-density lipoproteins in order to infect hepatocytes. There is no vaccination available.

Hepatitis C Spread through the blood, and possibly sexual contact, but there is no vaccine available. In order to infect hepatocytes, HCV coats itself with low-density and very low-density lipoproteins. 80% of patients develop chronic hepatitis. Treatment is IFN-α, and ribavirin can be considered.

This type of hepatitis is commonly associated with high fetal mortality.

Hepatitis E Spread through the fecal-oral route and is more common in developing countries. This type of hepatitis is associated with high fetal mortality when occurring in pregnant women.

A 32-year-old female with a family history of dementia presents with worsening hypotonia with hyperreflexia.

Huntington Disease Autosomal dominant neurodegenerative disorder. It is caused by a trinucleotide cysteine-adenosine-guanine repeat expansion on chromosome 4. The disease is characterized by choreiform movements, behavioral change and dementia. Chorea is the hallmark symptom of HD. Chorea is a rapid, arrhythmic and involuntary movement of the face, trunk, and limbs. Disorders in movement are the first symptoms to appear and develop insidiously with psychiatric and cognitive features. Hypotonia with hyperreflexia is a feature of early disease. As the disease progresses, chorea is replaced by a rigid, parkinsonian state. Abnormal eye movements are seen in early disease. Psychiatric symptoms include irritability, depression and social problems. Cognitive decline is defined as executive dysfunction with diminished ability to make decisions, multitask and difficulty with time. However, different from Alzheimer disease, memory loss is not a typical feature until advanced disease. Lastly, unintentional weight loss and cachexia are common. Diagnosis is clinical and based on a positive family history. Atrophy, neuronal loss with protein aggregates are seen in the caudate and putamen. HD is an incurable disease; treatment is supportive only.

A 54-year-old female presents to the emergency department with the complaint of lethargy. History reveals the patient has diabetes for which she takes oral hypoglycemic agents and was recently started on hydrochlorothiazide for hypertension. Physical examination reveals the patient is not oriented to time or place. Vital signs reveal a blood pressure of 88/49 mmHg, a heart rate of 115/min, and a temperature of 37.2°C (98.9°F). Laboratory results are obtained and seen here. Na+ 136 mEq/L K+: 4.2 mEq/L HCO3-: 25 mEq/L Glucose: 870 mg/dL BUN: 74 mg/dL Creatinine: 2.8 mg/dL The most likely diagnosis is

Hyperosmolar hyperglycemic state Profound dehydration. HHS is seen in patients who suffer from type 2 diabetes mellitus and typically presents with polyuria, polydipsia, mental status changes, and lethargy (coma in 25-50% of cases) secondary to the effects of dehydration. Several triggers can initiate this effect, including lengthy infections, stress, and dehydration, which is seen in the above case following the initiation of a diuretic. When distinguishing between diabetic ketoacidosis (DKA) and HHS, the first step is to determine whether the patient suffers from type 1 or type 2 diabetes mellitus. HHS is typically not seen in type 1 diabetics because adequate insulin production is required to prevent DKA from occurring first.

The patient is stabilized and eventually discharged from the hospital on Glyburide. The most likely side effect of this medication is

Hypoglycemia Hypoglycemia is the most common side effect associated with sulfonylurea oral hypoglycemics. Second-generation sulfonylureas, such as glyburide and glipizide, reduce serum glucose levels by increasing insulin secretion from pancreatic beta cells.

A 62-year-old female presents to the emergency department with the complaint of difficulty walking. She says that her legs have been getting progressively weaker. History reveals that her symptoms started approximately 3 days ago with tingling in her toes. She then began to notice that she was having trouble walking. Past medical history reveals recent gastroenteritis. Physical examination reveals bilateral lower extremity strength of 3/5 and lower extremity deep tendon reflexes 0/4 bilaterally. A lumbar puncture in this patient would most likely show

Increased protein and glucose with a normal cell count Guillain-Barre syndrome (GBS), which is an acute, often severe, autoimmune polyradiculoneuropathy. Acute inflammatory demyelinating polyradiculopathy is the most common subtype. GBS classically presents as an ascending paralysis. It is often associated with recent mild upper respiratory or gastrointestinal tract infections. Campylobacter jejuni infection, as well as other infections, have been implicated. Physical examination reveals loss of deep tendon reflexes and ascending weakness. Patients often complain of back pain, and there may be some mild sensory changes. Cranial nerves and the autonomic nervous system may be involved, and mechanical ventilation may be needed. Lumbar puncture will classically reveal an increased protein with normal cell count, also known as albuminocytologic dissociation. This may not be seen until the end of the first week of GBS symptoms. In addition, nerve conduction studies abnormalities are seen, but these may be absent or mild early in the course of GBS. Other disorders must be ruled out, and laboratory studies are helpful. Treatment should be started as soon after diagnosis as possible. IV immune globulin or plasmapheresis are used, which are equally effective, and supportive care and close monitoring in a critical care setting are needed. Most patients with GBS survive, with the majority reaching full functional recovery after months to 1 year.

A 34-year-old male presents to the office for a pre-employment physical after being interviewed for a job as an accountant. During the examination, he presents a form with a list of genetic tests the company is requesting to be completed for all potential salaried employees. The most appropriate initial course of action is to

Inform the patient that the employer has no right to demand this information Employers do not have the right to request confidential medical information from potential employees, and cannot require genetic testing to screen for employment. This is in violation of the Health Insurance Portability and Accountability Act, which protects privacy of patient's health-related information. The best course of action in this case would be to inform the patient that the employer has no right to request this information.

Isotonic Saline Patients who present with hyperosmolar hyperglycemic nonketotic coma (HHNKC) typically suffer from large fluid deficits requiring 1-2 liters of isotonic saline within the first 2 hours of presentation. Even higher volumes may be required when severe fluid depletion is appreciated. Once blood pressure and heart rate become adequate, the gold standard is to then switch to half-normal saline. When serum glucose reaches levels below 250 mg/dL, it is then appropriate to add dextrose to the IV fluid.

A 64-year-old female complains of visual hallucinations. Akinesia and preservation of memory are noted on examination.

Lewy Body Dementia Lewy body disease is a neurodegenerative that has features of both Alzheimer's and Parkinson's diseases. Lewy body dementia is characterized by visual hallucinations, dysautonomia, sleep disorders and neuroleptic sensitivity. The diagnosis of Lewy body disease is often a delayed diagnosis. However, Lewy body dementia differs from Alzheimer's disease in that memory loss is not the first presenting symptom. Impairments in attention, executive and visuospatial abilities present initially. Mental status is fluctuating. Patients typically have problems with work or driving difficulties. The key component of Lewy body dementia is parkinsonian symptoms that develop later in the disease. Neuroimaging shows atrophy of the brain with sparing of the hippocampus. Accumulation of round, eosinophilic intranuclear inclusions, called Lewy bodies, in the substantia nigra are seen on pathological examination. Lewy bodies are a result of abnormal alpha-synuclein conformation.

A 52-year-old non-compliant diabetic male develops blindness secondary to diabetic retinopathy. The patient is new to the practice and seeks to establish care with a primary care physician. The patient is of a low-income status, is unemployed, and has no insurance. Based on this information, he is eligible to receive

Medicaid Medicaid is means-tested and does consider an applicant's assets. In addition to low-income coverage, Medicaid is also available to persons who are aged, blind, disabled, or certain people in families with dependent children regardless of financial burden.

A 45-year-old male presents to the office with worsening dyspnea. History reveals he works a labor-intensive job in construction and stops working once daily due to increased wheezing. He currently takes a short-acting beta-2-agonist inhaler once daily when these symptoms occur. Once he takes the medication, he usually feels better within 15 minutes and is able to return to his normal activities. History reveals he sometimes wakes at night due to a cough, which occurs about twice per week. His symptoms occur even on the weekends when he is not working. He has been provided oral corticosteroids once this year to control an exacerbation of his asthma. Otherwise, his only medication is his albuterol inhaler. He quit smoking 5 years prior and drinks 1-2 beers on the weekends. Pulmonary function testing is obtained and reveals a forced expiratory volume (FEV1) of 70% and an FEV1/forced vital capacity ratio of 75% of predicted value. What classification of asthma severity best describes this patient?

Moderate persistant

A 35-year-old female has missed several primary care appointments over the past two years. She calls many times, demanding refills on her narcotics, and refuses all attempts at preventative care. After an attempt to forge the physician's signature on a prescription, the physician decides to dismiss the patient from the practice. What obligation does the physician have to this patient?

Must provide copies of all patient paperwork if requested A termination letter should be written and preferably sent by certified mail to document it was sent and received. The letter should include the reason for termination, an effective date (usually 30 days is considered adequate time unless there is risk of violence), list interim care providers and mention where emergency care should occur, and offer to provide a copy of medical records to the new provider if requested. Although there can be many reasons for termination, here are some situations where termination is considered appropriate and acceptable: treatment noncompliance, follow-up noncompliance, office policy noncompliance, verbal abuse or violent behavior, and nonpayment. Delay of termination may be needed if the patient is in an acute phase of treatment, if the physician is the only source of medical care within a reasonable driving distance, if the physician is the only source of a particular type of medical care, or if the patient is a member of a pre-paid health plan.

A 34-year-old man presents to his primary care doctor with several episodes of vertigo, tinnitus, and hearing loss of the left ear. He also complains of a feeling of fullness in the left ear. He denies any loss of consciousness or recent illnesses. The patient states that these symptoms have come and gone for the past 2 years but have recently become more frequent. The Weber test is performed and it lateralizes to the right ear. The Rinne test is heard equally in both ears. The rest of the head and neck exam is normal. An audiogram demonstrates a low-frequency hearing loss in the left ear and no hearing loss in the right ear. What is the most likely diagnosis?

Ménière disease Ménière disease is characterized by vertigo, tinnitus, and hearing loss. Patients with this condition also often report a sense of fullness in the affected ear. Diagnosing Ménière disease is difficult because symptoms can come and go and patients often don't seek treatment until symptoms become severe. In-office testing may include Weber-Rinne testing; given that Ménière disease causes a sensorineural hearing loss, this combined testing will reveal lateralization of Weber to the contralateral 'normal' side and a normal Rinne test. An audiogram can be ordered for patients to help determine if there is true hearing loss. Ménière disease typically results in a loss of ability to hear low frequencies with preservation of hearing high frequencies. Treatment of Ménière disease typically starts with lifestyle modifications, such as avoiding alcohol, caffeine, and high-salt foods. Acute episodes can be treated with antiemetics and vestibular suppressants. Diuretics are sometimes used to prevent episodes alongside lifestyle changes.

A 45-year-old right hand-dominant female presents to the office complaining of right shoulder pain that has been getting worse during the past 3 months. She works in a warehouse and stocks boxes on shelves daily. History reveals the pain is located in the superolateral aspect of the shoulder and radiates to the deltoid; the pain is exacerbated with brushing her hair and relieved when she puts her arm down by her side. Physical examination of the right shoulder reveals decreased active range of motion in forward flexion and abduction secondary to pain but no with muscle weakness. She is neurovascularly intact distally and has no history of previous injuries.

Neer sign Subacromial impingement syndrome. Impingement syndrome is a spectrum of disease in which the rotator cuff muscles and tendons (most commonly the supraspinatus and infraspinatus) become inflamed and impinged between the acromion/distal clavicle and the humeral head. Pain is generally insidious in onset. The end result of chronic, repetitive micro-trauma and impingement to the rotator cuff is a rotator cuff tear. The supraspinatus muscle is by far the most common rotator cuff muscle involved in shoulder impingement syndrome. Special tests for subacromial impingement include Neer's sign and Hawkin's test. Most appropriate test for diagnosing tears of rotator cuff is MRI

Several months later, the patient presents to the emergency department due to acute onset of dyspnea. He is taking deep breaths between 2- to 3-word phrases, has diminished breath sounds bilaterally, and is using accessory muscles of respiration. His respiratory rate is increasing and is currently 35/min. You ask the nurse to check his oxygenation saturation by pulse oximetry and it registers at 82%. An arterial blood gas soon reveals a pH of 7.34. Which of the following is most appropriate next step?

Non invasive ventilation Noninvasive positive pressure ventilation (NPPV) is the preferred method of respiratory support for acute exacerbations of chronic obstructive pulmonary disease (COPD) with evidence of acute respiratory failure. NPPV refers to mechanical ventilation delivered without initiating an artificial airway. There are various mechanisms of action including continuous positive airway pressure and bilevel positive airway pressure (BPAP). BPAP is commonly used to treat COPD exacerbations: It reduces the respiratory load and diaphragmatic work of breathing and increases tidal volume, resulting in an improvement in oxygenation. Intubation should be considered in patients who are not spontaneously breathing on their own or are unable to protect their airway. This patient is still sitting up and able to breathe on his own. If the patient's pulse oximetry does not improve with NPPV, then intubation should be considered.

A 21-year-old male presents to the urgent care clinic on crutches with lateral right ankle pain and swelling. History reveals that the patient suffered an inversion injury to his ankle while playing basketball a few hours prior to exam. Immediately after the injury the patient was not able to bear weight. Evaluation reveals a healthy, adult male. He is unable to transfer weight between feet in the urgent care clinic when prompted. Physical exam reveals significant tenderness along the distal tip of the lateral malleolus with moderate swelling and ecchymosis over the lateral ankle. The patient denies tenderness along the medial malleoli, as well as at the base of the fifth metatarsal and navicular. There is no report of pain along the dorsum of the foot. The patient is able to dorsiflex and plantarflex the foot with mild discomfort. Eversion and inversion are very painful. Mild weakness is demonstrated with eversion against resistance. The most appropriate next step is to

Obtain x-ray imaging of ankle Patient MUST HAVE ONE of the following, plus ONE of the associated "additional criteria": 1. Pain in the malleolar zone (lateral or medial) a. Bone tenderness at the posterior edge or distal tip of the affected malleolus OR b. Unable to bear weight immediately after the injury, and for four steps in the ED/urgent care clinic 2. Pain in the midfoot zone a. Have bone tenderness at the base of the fifth metatarsal or navicular OR b. Unable to bear weight immediately after the injury, and for four steps in the ED/urgent care clinic

A 72-year-old male new patient presents to your office with progressive dyspnea on exertion and a productive cough of yellow-grey sputum for 1 week. History reveals that he has had several similar episodes during the last few years. Between episodes, he reports a chronic daily cough with mild sputum production. He denies any previous workup. Past medical history is significant for hypertension, for which he receives losartan. Social history reveals a 40 pack-year smoking history. Vital signs reveal a temperature of 37.4°C (99.4°F), a blood pressure of 140/98 mmHg, a heart rate of 89/min, and a respiratory rate of 25/min. Physical examination exhibits a mildly obese male hunched forward. Lung sounds are diminished bilaterally with expiratory wheezes. You note paravertebral hypertonicity and fullness from T2-5, T3 FRRSR, ribs 3 exhalation somatic dysfunction on the right, a bilateral diaphragm restriction, and muscle spasms in the scalenes bilaterally. You obtain a chest radiograph in your office, which demonstrates hyperinflation without any acute infiltrates. Given his likely underlying etiology, you then provide him with an albuterol inhaler as well as which short-term medication?

Oral glucocorticoid Treatment of acute exacerbations of COPD primarily involves beta-2 agonists and short-term oral glucocorticoids. Anticholinergic medications should be used as first-line long-term therapy in an effort to control the patient's symptoms. Hospitalized patients may benefit from antibiotic use. Any patient with hypoxia should be given supplemental oxygen. This patient is having a mild to moderate exacerbation that can be treated as an outpatient. He should be given a beta-2 agonist and glucocorticoids. In the long term, he will be started on inhaled anticholinergics, possibly in combination with an inhaled corticosteroid if he needs improved control.

Neer's Sign

Passively forward flexing the patients shoulder past 90° with one hand while stabilizing the shoulder with the other hand. Pain with this maneuver is a positive test (sensitivity 72%, specificity 60%). Neer's sign is performed by injecting the subacromial space with local anesthetic and getting relief of pain with > 90° of passive shoulder forward flexion.

A 60-year-old male presents with painful sores in the mouth and gums that bleed easily when brushing his teeth. There are also painful blisters on his chest that are fragile and easily slough off. Nikolsky's sign is positive. Skin biopsy shows separation of epidermal cells with an intact basement membrane.

Pemphigus vulgaris Autoimmune bullous disorder of the skin, characterized by the presence of autoantibodies directed against adhesion molecules (specifically desmoglein 3) in the epidermis and usually manifests in patients middle-aged or older, although it can uncommonly be seen in teenagers. It presents with painful, fragile blisters in the oropharynx, chest, and face. Sores often originate in the mouth, making it difficult for patients to eat. The blisters can also involve the nasal mucosa, conjunctiva, vagina, penis, and anus. Nikolsky's sign is positive. Biopsy of the skin shows separation of the epidermal cells with retention of an intact basement membrane. This process is known as acantholysis. Anti-epidermal antibodies are demonstrated by immunofluorescence.

Hawkin's test

Performed by placing the shoulder in 90° of forward flexion and then, with the elbow bent, internally rotating the shoulder. This brings the greater tuberosity (the attachment site of commonly impinged rotator cuff tendons) into greater contact with the undersurface of the acromion and coracoacromial ligament. Pain with internal rotation is considered a positive test (sensitivity 62% to 92%, specificity 25% to 100%).

A 22-year-old male presents to the clinic with the complaint of episodic anxiety. The history reveals these symptoms began suddenly 3 months ago and each episode lasts about an hour, with the last episode being a week ago. In between episodes, he feels no anxiety. The episodes begin with a headache and a racing heart followed by diaphoresis. He denies any sense of worry or obvious triggers. Medical history reveals a thyroidectomy due to a benign thyroid adenoma, after which he has taken levothyroxine. His vital signs reveal a blood pressure of 162/98 mmHg, a heart rate of 108/min, and a body mass index of 22 kg/m2. He is an otherwise well-appearing male with a normal sounding heart and lung exam. Lab work demonstrates a normal complete blood count, basic metabolic panel, and hemoglobin A1c. His thyroid stimulating hormone demonstrates that he is currently euthyroid on his medications. The patient's testing confirms the previous diagnosis. With a confirmed diagnosis, the most appropriate initial management is

Phenoxybenzamine (prior to surgical resection) Alpha blockers prevent norepinephrine from binding to vascular smooth muscle, resulting in vasodilation. Irreversible alpha blockade from phenoxybenzamine will prevent an intraoperative hypertensive crisis that can result from catecholamine release from manipulation of the tumor.

A 42-year-old alcoholic and cocaine addict presents with emotional blunting and loss of empathy.

Picks Disease (Frontotemporal dementia) Neurodegeneration disease of the frontal and/or temporal lobes. Patients present with personality change and inappropriate social conduct, loss of social awareness and insight with blunt emotional responses. Eventually these symptoms develop into a more global dementia. Different from Alzheimer's disease, memory and visuospatial skills are often preserved. Also, FTD progresses more rapidly than Alzheimer's disease. In FTD serotonergic deficits occur with relative sparing of acetylcholine function. Neuroimaging shows bifrontal atrophy without evidence of amyloid plaques or neurofibrillary tangles which are seen Alzheimer's disease.

After managing his acute exacerbation (of COPD), the patient returns to the office for follow-up in the summer, when you discuss smoking cessation. Before he leaves the office, which of the following is the most important intervention to complete?

Pneumococcal vaccination Most important interventions for patients with stable chronic obstructive pulmonary disease (COPD) are smoking cessation, influenza and pneumococcal vaccination, and supplemental oxygen if the patient has baseline hypoxia. Smoking cessation is the most important lifestyle modification in COPD as it very clearly improves symptoms and decreases mortality. Pneumococcal and influenza vaccinations decrease exacerbations and hospitalizations, but the data are mixed on whether they improve mortality. Influenza vaccination should be given yearly during the appropriate fall/winter seasonal recommendations. Supplemental oxygen improves mortality for patients with COPD, especially those with severe hypoxia at baseline. Influenza vaccination is given during the fall/winter time period, and our patient is presenting in the summer. Therefore, influenza vaccination would be postponed at this time.

A 53-year-old male with a history of high blood pressure presents with chronic blistering on his neck, chest, and hands. He notes his skin was normal throughout his life, but over the past two years he began to notice blisters and erosions that have gotten progressively worse. He admits to daily alcohol intake and smokes a half pack of cigarettes a day. Physical exam reveals hemorrhagic blisters, hyperpigmentation, and hypertrichosis of the dorsal hands and forearms. There are also areas of dyspigmentation with small superficial cysts. In addition, some nail plates have separated from the nail bed.

Porphyria Cutanea Tarda Autosomal dominant pattern about 20% of the time or sporadically acquired about 80% of the time. PCT results from deficiency of hepatic uroporphyrinogen decarboxylase, an enzyme involved in the metabolism of heme. Uroporphyrins accumulate in the skin, and in the presence of sunlight at 400-410nm porphyrins release energy resulting in reactive oxygen species that then damage the skin. This disorder is exacerbated by excessive alcohol intake, hepatitis C, smoking, or estrogen use. Patients (such as in the above scenario) typically present with chronic blistering on sun-exposed areas that fail to heal properly and are often hemorrhagic, resulting in erosions, milia (small superficial cysts), and hyperpigmentation of the skin. This most commonly affects the dorsal hands and forearms. In addition, patients often have hypertrichosis. Look for decreased levels of uroporphyrinogen decarboxylase with increased levels of porphyrins in the serum, urine, and feces. Urine may fluoresce under a Wood's lamp after being acidified with 10% HCl or acetic acid. Treatment involves cessation of alcohol and tobacco use, sun avoidance, antimalarials, and periodic phlebotomy.

Raloxifene The National Osteoporosis Foundation also recommends pharmacologic treatment of women who have a history of hip or vertebral fracture, and/or osteoporosis based upon BMD (T-score ≤ −2.5). Typically, oral bisphosphonates, such as alendronate or risendronate, are first-line pharmacologic therapy owing to their availability and low cost. This is a viable option for this patient. However, given her remote history of breast cancer, raloxifene should be used owing to its prophylactic effects against breast cancer.

An 87-year-old female presents to the office for a routine annual examination. The patient states that she has been living with her daughter and son-in-law. She states the son-in-law locks her in the bedroom at night and is verbally and physically abusive to her at times. You have known the patient for many years and have no reason to believe she is fabricating this story. The most appropriate action to take is

Report the son-in-law to adult protective services for elderly abuse Elder abuse is a serious issue that should not be taken lightly by the physician. Legally, the physician is obligated to report abuse in most, but not all, states. The ethical obligations of the physician, however, require full report of all forms of elderly abuse to adult protective services. Although physical abuse is the most apparent form, mental and emotional abuse can have an equal or even greater impact on a patient's well-being.

Surface antigen negative E-antigen negative Core antibody IgG positive Surface antibody positive

Resolved, past infection Hepatitis B surface antigen and e-antigen rise and fall early in the course of infection (between 8 and 20 weeks for the surface antigen and 8 and 24 weeks for the e-antigen). The core antibody begins to rise at around 12 weeks and can remain positive. It is IgM during the acute phase and transitions to IgG when chronic or resolved. The surface antibody begins to rise later in the course and is positive in vaccinated individuals and in resolved infections.

A 19-year-old right-hand dominant male professional snowboarder presents to the office with the complaint of left wrist pain for 1 week. History reveals that the pain began after a fall onto his hand while snowboarding. The pain is partially improved with ice and immobilization. Physical examination reveals edema and tenderness at the radial side of the left wrist, near the base of the thumb. A hand radiograph is obtained as shown in the exhibit.

Scaphoid The most common carpal bone fractured is the scaphoid (78%), followed by the triquetrum (13.8%). The mechanism of injury is generally a fall on an outstretched hand. This position causes a forced hyperextension and radial deviation of the wrist, with the resultant force being directly transferred through the radioscaphoid articulation with the concentration primarily on the scaphoid. The location of the fracture in the scaphoid is of significance as the blood supply to the bone enters distally. Therefore, fractures at the proximal end of the bone are extremely likely to undergo nonunion or avascular necrosis (AVN). The most common location of scaphoid fractures occurs at the waist, which has approximately a 30% risk for AVN. This is demonstrated in the radiograph in the question stem. On examination, patients have snuffbox tenderness (radial-sided wrist pain at the base of the thumb, in the anatomic snuffbox), swelling, and limited wrist and thumb range of motion. Fracture is nondisplaced, place thumb in spica cast. If there is clinical concern for fracture, the affected wrist should be immobilized, and repeat radiographs at 2 weeks are required to make the diagnosis. If there is still concern for fracture and radiographs are equivocal, MRI can be diagnostic for occult fracture.

A 39-year-old male presents with a 2-week history of constant, aching, nonradiating hip pain, which he states is not improved with over-the-counter medications including acetaminophen and ibuprofen. He reports mild relief with heat and lying prone with a pillow under his pelvis. Pain is aggravated with prolonged sitting at work. He is noted to have 5/5 strength in hip flexion, knee extension, knee flexion, foot dorsiflexion, and plantar flexion, with sensation intact in L2 to S2 dermatomes bilaterally. Reflexes are symmetric and normal at the knee and ankle. On osteopathic structural examination, there is significant tenderness to palpation along the left posterior superior iliac spine (PSIS) with a positive standing flexion test on the left and negative seated flexion test. While supine, the patient has more motion on right anterior superior iliac spine (ASIS) compression, a right superior ASIS, and right inferior PSIS. After determining there are no contraindications, the somatic dysfunction is treated with muscle energy. How should the patient be positioned to treat this in the supine position?

Standing on the left side while flexing left hip to its restrictive barrier with the physicians left hand Patient pushes their leg towards their feet against counter resistance for 3-5 seconds prior to relaxing Left anterior rotated innominate

A 67-year-old truck driver presents to the office complaining of low back pain that has been progressing over the last few months. The pain is now radiating into the right leg to the big toe. Physical examination reveals tenderness over the right lower back and weakness in dorsiflexion of the right big toe. There is decreased sensation to light touch over the first dorsal web space of the right foot. The most appropriate next step to aid in the diagnosis is

Straight leg raise Herniated discs are a common cause of low back pain and lower extremity weakness. The most common level is L5/S1, followed by L4/L5. A weakness in the annulus fibrosis allows expulsion of the nucleus pulposus into the spinal canal, thereby compressing the nerve. Depending on the level of herniation, patients may experience low back pain, radicular pain, and possibly cauda equina syndrome. If the L4 nerve root is affected, ankle dorsiflexion will be diminished. If L5 is affected, there will be weakness of the extensor hallucis longus (great toe extensor) as seen in the patient in this case. The examination should consist of a straight leg raise, which will place tension on the affected nerve and recreate the patient's symptoms.

A 72-year-old male presents the office with the complaint of right shoulder pain. He states he noticed the pain several months ago and it is worsening. The pain is currently a 6/10 and is worst when reaching over his head. The pain is better with rest but some nights he wakes up because of the pain. Physical examination reveals no visible deformities, no crepitus, and strong pulses of the upper extremities. There is normal muscle strength with forward flexion, extension, internal rotation, and external rotation. There is 3/5 muscle strength with abduction of the right shoulder in comparison to the left. The patient's pain is exacerbated with muscle strength testing when you place their shoulder in ninety degrees of abduction, thirty degrees of forward flexion and internally rotate the arm so that the thumb is pointing down to the floor. A radiograph of the right shoulder is obtained and is unremarkable. The nerve that innervates the muscle that is causing the most likely diagnosis is

Suprascapular nerve Pathology of the supraspinatus tendon. This includes a supraspinatus tendon tear, a tendinitis, or impingement syndrome. The most common pathology of the rotator cuff occurs with the supraspinatus muscle as its tendon traverses beneath the acromion process of the scapula. It is innervated by the suprascapular nerve.

A 38-year-old male presents to the office with the complaint of painful walking and the inability to push off. He had felt a sudden, painful pop in the back of his leg when he had been carrying heavy boxes off his boat 3 days ago. He says that it "felt like he was shot in the leg." Physical examination reveals ecchymosis around the lower calf and ankle with a noticeable depression in the lower calf. You also note paravertebral hypertonicity and tenderness from T11-L2. The physical examination findings that would most likely confirm the patient's diagnosis is

Thompson test Traumatic rupture of the Achilles tendon. The most common mechanism is due to a forceful dorsiflexion from a plantarflexed position. This leads to a strong eccentric load on the tendon that results in tearing. Alternatively, a forceful contraction of the gastrocsoleus can also cause rupture. Patients usually complain of a very painful "pop," as if they were shot with a gun or hit with a bat. TART changes may be evident from T11-L2, representative of viscerosomatic reflexes from the lower extremity. Traumatic Achilles tendon ruptures typically occur in men, between 30 and 40 years of age. In the patient history, they are often "weekend warrior" types. However, ruptures are also seen in athletes, especially football players. In the days following the event, there will be ecchymosis surrounding the area of the ruptured tendon and a visible depression or divot can be appreciated on the surface of the skin, where the rupture is. The most sensitive and specific study to confirm the diagnosis: MRI (good for soft tissues) Treatment: long leg cast with 20° plantarflexion for 2 weeks, follwed by progressive weight bearing and therapy

A 53-year-old male presents to the office for a yearly health maintenance visit. Physical examination reveals an obese patient with a waist circumference of 41 inches. His blood pressure is 129/84 mmHg. He does not exercise at all and works at a sedentary job. He has a family history of early heart disease; his father had a myocardial infarction at the age of 49. He is not currently on any medications. Given his risk factors, you are concerned about his metabolic health. Therefore, you obtain labs, including a fasting plasma glucose and lipid panel. Which of the following collection of lab results, combined with the description above, would fulfill the criteria for metabolic syndrome in this patient?

Triglycerides 198mg/dL, HDL 38 mg/dL, Fasting plasma glucose 103 mg/dL Metabolic Syndrome (Syndrome X or Insulin resistance syndrome) Adult Treatment Panel III Metabolic Syndrome Criteria—The Presence of any Three of the Following Five Traits 1. Abdominal obesity, defined as a waist circumference in men ≥ 102 cm (40 in) and in women ≥ 88 cm (35 in) 2. Serum HDL cholesterol < 40 mg/dL in men and < 50 mg/dL in women OR drug treatment for low HDL cholesterol 3. Serum triglycerides ≥ 150 mg/dL OR drug treatment for elevated triglycerides 4. Fasting plasma glucose ≥100 mg/dL OR drug treatment for elevated blood glucose 5. Blood pressure ≥ 130/85 mmHg OR drug treatment for elevated blood pressure

Surface antigen negative E-antigen negative Core antibody negative Surface antibody positive

Vaccinated Hepatitis B surface antigen and e-antigen rise and fall early in the course of infection (between 8 and 20 weeks for the surface antigen and 8 and 24 weeks for the e-antigen). The core antibody begins to rise at around 12 weeks and can remain positive. It is IgM during the acute phase and transitions to IgG when chronic or resolved. The surface antibody begins to rise later in the course and is positive in vaccinated individuals and in resolved infections.

A 71-year-old male presents with a sudden progression in his short-term memory loss. Over the past few years his daughter recalls several instances where his symptoms abruptly deteriorated and led to his inability to follow instructions and difficulty with balance while walking.

Vascular Dementia Dementia secondary to vascular injury is the second most common cause of dementia. Risk factors include hypertension, smoking, diabetes mellitus and hyperlipidemia. Most cases of vascular dementia are sporadic and evolve after stroke. Individuals with vascular dementia present with an abrupt deterioration in motor or cognitive function and tend to progressively decline in a sudden step-wise fashion. Cognitive screening tools are remarkable for patchy deficits unlike Alzheimer's disease which shows diffuse deficits with slow, steady progression. Physical examination is remarkable for focal neurological findings such as hemiparesis, visual field deficits and hemisensory defects. Gross ischemic infarcts, lacunar infarcts, and arteriosclerosis with minimal atrophy are apparent on neuroimaging.

A 20-year-old female athlete presents with the complaint of anterior knee pain. She states that she notices it most after getting out of her chair from her 3-hour economics lecture and that she has particular trouble ascending and descending stairs. The pain has been gradual in onset and tends to improve with physical activity. Physical examination reveals crepitus and a patella that tracks laterally. Lachman's and McMurray's tests are negative. The most likely cause of her diagnosis is

Weakness of vastus medialis obliquus Patellofemoral syndrome. Also known as chondromalacia, the term patellofemoral syndrome is more accurate because in order to diagnose chondromalacia with 100% certainty, one would need a tissue sample. Patellofemoral syndrome is a relatively common cause of anterior subpatellar knee pain that is typically worse after prolonged periods of sitting and when ascending and descending stairs and usually improves with walking. It is typically caused by altered biomechanics secondary to trauma, muscular imbalances, effusions, and/or meniscal tears. Examination may reveal patellar maltracking, muscular atrophy, crepitus, locking, and/or instability. Plain radiographs are typically normal. Treatment consists of addressing the underlying biomechanical imbalances through physical therapy. In this particular patient (which is also the most common presentation), the patella was noted to be tracking laterally. This is indicative of weakness of the vastus medialis obliquus (VMO), which is the most distal portion of the vastus medialis muscle as the fibers turn more obliquely and attach to the medial aspect of the patella. Weakness of the VMO allows the vastus lateralis to dominate and pull the patella laterally

Surface antigen negative E-antigen negative Core antibody IgM and IgG positive Surface antibody negative

Window period Hepatitis B surface antigen and e-antigen rise and fall early in the course of infection (between 8 and 20 weeks for the surface antigen and 8 and 24 weeks for the e-antigen). The core antibody begins to rise at around 12 weeks and can remain positive. It is IgM during the acute phase and transitions to IgG when chronic or resolved. The surface antibody begins to rise later in the course and is positive in vaccinated individuals and in resolved infections.

A 43-year-old right-hand dominant male presents to the urgent care clinic for evaluation of right shoulder pain. History reveals that the patient was in his usual excellent state of health until yesterday evening while participating in a martial arts class. The patient elaborates that during the class he was sparring with an opponent and was knocked to the ground, falling onto his right shoulder with an adducted arm. He immediately felt pain in his right shoulder. The pain is localized over the superolateral aspect of the shoulder without radiation to the right hand. The pain has not subsided since onset. He denies any previous injuries to the affected shoulder joint. Examination reveals severe tenderness to palpation over the right acromion process. He reports pain when his right shoulder and elbow are placed in 90 degrees flexion and he attempts to touch his left shoulder. When his right arm is placed in 90 degrees flexion and complete internal rotation, pain and weakness is elicited when the physician applies downward pressure. He is also unable to actively hold his arm in 90 degrees of abduction. His Yergason test is negative. The best initial step in his management is to perform

X-ray series of the right shoulder Sprain or separation of his right acromioclavicular joint. The positive Empty Can and Drop Arm test also suggest rotator cuff pathology.

A 48-year-old African-American female recently diagnosed with type 2 diabetes mellitus visits her primary care physician for a follow-up appointment. The physician states that the patient does not require medications at this time but recommends blood pressure control less than 130/80 mmHg, HbA1C < 7%, follow-up appointments every 3-6 months, as well as lifestyle changes that include exercise and a reduction in simple carbohydrates in her diet. In addition, this patient should be screened for

Yearly dilated retinal exam, foot exam, and microalbuminuria screening Type 2 diabetes mellitus is characterized by insulin resistance and relative insulin deficiency. Complications include non-proliferative retinopathy with dot and blot retinal hemorrhages, cotton-wool spots, protein exudates, and progression to proliferative retinopathy characterized by neovascularization, vitreous hemorrhage, retinal detachment, and blindness. Similarly, nephropathy that can progress to renal failure, and neuropathy that progresses from sensory loss to motor paralysis are common complications. As a result, the screening recommendations for patients with type 2 diabetes mellitus are yearly dilated retinal exams, foot exams, and for microalbuminuria to monitor progression of the disease.

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