quizlet NBME 14

A 30-year-old woman comes to the office for a health maintenance examination. She has had occasional shortness of breath during the past year but is otherwise healthy. She has no history of major medical illness and takes no medications. She is concerned because her father and paternal second cousin have a 1-antitrypsin deficiency and she would like to know if she is at risk for developing the disease. Vital signs are within normal limits. Examination shows noabnormalities. Which of the following is the most appropriate next step in diagnosis?Acquirepatientconsentforgenetictesting

Educational Objective: a1-Antitrypsin deficiency results in the early development of panacinar emphysema and liver disease. It is a hereditary disease resulting from deleterious mutations in SERPINA 1, which is located on the long arm of chromosome 14 and encodes a1-antitrypsin. The mutation is inherited in an autosomal codominant fashion. The diagnosis is confirmed with genetic testing.

A 56-year-old woman with recurrent ovarian cancer is admitted to the hospital for management of inoperable small-bowel obstruction. Despite undergoing four courses of chemotherapy during the past 5 years, the cancer continues to progress. She currently takes no medications. A nasogastric tube is placed. Her temperature is 37°C (98.6°F), pulse is 80/min, respirations are 12/min, and blood pressure is 120/70 mm Hg. Abdominal examination shows distention and decreased bowel sounds. Which of the following is the most appropriate next step in management? B)Family meeting to determine goals of care C) lleostomy D) Intravenous total parenteral nutrition E) Placement of a percutaneous gastrostomy tube

Educational Objective: b is correct. As patients near the end of their life, physicians should facilitate discussions with the patient and their family to clarify their wishes for ongoing care. Some patients may favor life-prolonging interventions while others may opt to prioritize quality of life. Hospice care is a model of health care that prioritizes quality of life over prolongation of life.

What is infectious mononucleosis? How is Epstein-Barr virus transmitted? Who is commonly affected by infectious mononucleosis? Which cell type is infected in infectious mononucleosis? What type of lymphocytes are seen on peripheral blood smear? What are the clinical features of infectious mononucleosis? What is the monospot test used for? What can be seen on liver function testing in infectious mononucleosis? Is liver function testing necessary for all patients with infectious mononucleosis? Why should patients with infectious mononucleosis avoid contact sports? What can be seen on peripheral blood smear in infectious mononucleosis?

Viral illness caused by Epstein-Barr virus. Through respiratory secretions and saliva. Teenagers and young adults. B lymphocytes. Cytotoxic, CD8+ T lymphocytes. Fever, lymphadenopathy, hepatosplenomegaly, and pharyngitis. Detecting heterophile antibodies.works by Agglutination of sheep or horse erythrocytes. Mildly increased transaminases, alkaline phosphatase, and bilirubin No, but may be desirable in certain circumstances. Due to the risk of splenic rupture. Atypical lymphocytes.

What is caudal regression syndrome? What is the cause of caudal regression syndrome? What is the theorized pathophysiology of caudal regression syndrome? What are the clinical features and symptoms of caudal regression syndrome? Can fetuses with caudal regression syndrome survive birth? What are the features of this patient's fetus with caudal regression syndrome? What is the significance of minimal differentiation of bilateral lower extremities in caudal regression syndrome? What is the significance of low amniotic fluid index in caudal regression syndrome? What is the relationship between caudal regression syndrome and diabetic embryopathies? What is the association between caudal regression syndrome and diabetes in the mother? What are the potential consequences of abnormal myoinositol uptake in caudal regression syndrome? What are the concurrent abnormalities commonly seen in caudal regression syndrome?

-Congenital condition with absence of sacrum and lower lumbar spine. -Anomaly in embryo associated with diabetes in the mother. -Abnormal myoinositol uptake leading to abnormalities in arachidonic acid and prostaglandin pathway. -Dependent on spinal lesion level and severity, commonly includes anorectal malformations and sacral aplasia. -Possible, but those with significant abnormalities are unlikely to survive gestation. -Minimal differentiation of bilateral lower extremities and low amniotic fluid index. -It is a characteristic feature of the condition. It is likely incompatible with life. Caudal regression syndrome falls under the umbrella of diabetic embryopathies. It is associated with poor control of diabetes and hyperglycemia prior to and during pregnancy. Abnormalities in arachidonic acid and prostaglandin pathway, leading to birth defects and early pregnancy loss. Anorectal malformations and aplasia of the sacrum.

What is transient synovitis? Which joint is commonly affected by transient synovitis? Is transient synovitis associated with long-term complications? Who does transient synovitis classically present in? What are the symptoms of transient synovitis? Are vital signs generally within normal limits in transient synovitis? What are the increased markers of inflammation in transient synovitis? What conditions should be excluded in the diagnosis of transient synovitis? What is the treatment for transient synovitis? What should be done if there is diagnostic uncertainty in transient synovitis?

-Inflammatory condition involving synovial lining of weight-bearing joints. -Hip. -No. -Children recovering from a viral infection. -Pain on weight bearing, antalgic gait, refusal to ambulate, tenderness over the joint, pain with range of motion. -Yes. -Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). -Cellulitis, septic arthritis, osteomyelitis, and fracture. -Supportive, rest, and nonsteroidal anti-inflammatory drugs. -Perform arthrocentesis to exclude septic arthritis and imaging to assess for osteomyelitis or fracture.Transient synovitis typically resolves in 1 to 2 weeks without long-term complications.

A 37-year-old man comes to the physician because of a 2-week history of fever, progressive fatigue, abdominal pain, nausea, and vomiting. He also has had dark urine and clay-colored stools during this time. Six weeks ago, he traveled to Central America where he ate the local food, including raw shellfish and vegetables. His temperature is 38°C (100.4°F), pulse is 90/min and regular, respirations are 20/min, and blood pressure is 110/85 mm Hg. Examination shows scleral icterus. The liver is tender and palpated 6 cm below the right costal margin. E) Complete resolution of symptoms What are the presenting findings of acute hepatitis A virus (HAV) infection? How is HAV transmitted? What are the common sources of HAV infection? What is the incubation period of HAV? What are the signs and symptoms of HAV infection? Are all patients with HAV infection symptomatic? What are the laboratory findings in HAV infection? How is the diagnosis of HAV infection confirmed? Does HAV infection progress to chronic infection?

-Nausea, vomiting, abdominal pain, icterus, hepatomegaly, and right upper quadrant tenderness. -Through fecal-oral transmission. -Poorly cooked, improperly handled, or raw foods, including shellfish. -Several weeks. -Fever, nausea, vomiting, poor appetite, abdominal pain, jaundice, and hepatomegaly. -No, many patients are asymptomatic. -Transaminitis, increased alkaline phosphatase, hyperbilirubinemia, and bilirubinuria. -By the serologic detection of anti-HAV IgM antibodies. -No, it is typically a self-limited illness.

What are the classic symptoms of UTIs in women? What can happen if UTIs are left untreated? What are the typical findings on urinalysis in UTIs? Why is prescribing an antibiotic following sexual intercourse appropriate for this patient? What is a common antibiotic used to treat cystitis?

Dysuria, urinary frequency, urgency, and suprapubic discomfort. Bacteria can travel up the ureter and infect the kidney, leading to pyelonephritis. Leukocyte esterase, nitrites, and WBCs on microscopy. Because her UTIs are reliably triggered by sexual intercourse.sex introduces bacteria to the urethra. women are more susceptible to infections because they have a shorter urethra. Nitrofurantoin.safe for pregos Ciprofloxacin can cross placenta and is harmful to a fetus. can cause damage to bone, cartilage, and tendons.

What are the consequences of testicular torsion? What are the classic symptoms of testicular torsion? What is the cremasteric reflex? What additional symptoms may occur before scrotal pain? What may be observed on physical examination? How is testicular torsion diagnosed? What does ultrasonography show in testicular torsion? What is the management for testicular torsion? What does orchidopexy involve?

Edema, ischemia, and necrosis. Acute testicular pain, tenderness, scrotal swelling. Diminished or absent in testicular torsion. Nausea, emesis, lower abdominal pain. High-riding testis, transverse orientation, erythema. Clinical diagnosis, ultrasonography if unclear. Diminished or absent blood flow to the testes. Emergency orchidopexy (surgical evaluation). Detorsion of testes and testicular fixation to prevent recurrence.

25. A study is conducted to assess whether a new drug used to treat type 2 diabetes mellitus is associated with an increased risk for developing cancer. In the study, a meta-analysis is performed of six small clinical trials of the new drug, and the relative risk for cancer development is determined. The results of the meta-analysis are shown in the graph. Which of the following conclusions can be drawn from these data?

Educational Objective: A meta-analysis is a form of study in which statistical analysis is performed to combine the results of multiple studies addressing the same question. Meta-analysis is useful for overcoming limitations of the constituent studies. By pooling the results of multiple studies, meta- analyses reduce the risk of type II error due to the smaller sample sizes within each constituent randomized controlled trial. A vertical line centered on the relative risk of 1.0 may or may not be shown in the center of the forest plot representing the line of null effect. A result is statistically significant and unlikely due to chance when its confidence intervals do not include 1.0 or the line of null effect.

A42-year-old man comes to the physician as a new patient. He has hypertension well controlled with lisinopril. He has no history of serious illness. He is 178 cm (5 ft 10 in) tall and weighs 66 kg (145 lb); BMI is 21 kg/m 2. His temperature is 37°C (98.6°F), pulse is 72/min, respirations are 12/min, and blood pressure is 120/70 mm Hg. Cardiopulmonary examination shows no abnormalities. The abdomen is soft and nontender; there are no masses. There is no edema of the extremities. Results of laboratory studies, including a complete blood count, are within the reference ranges. Urine dipstick is positive for blood. Which of the following is the most appropriate next step in diagnosis?Microscopic examination of urinary sediment

Educational Objective: A urine dipstick positive for blood can be due to RBCs, RBC casts, or myoglobinuria. Microscopic examination of urinary sediment can help differentiate the cause of a positive urine dipstick.

A 34-year-old woman, gravida 1, para 1, comes to the physician because of a 3-month history of heavy vaginal bleeding with large clots. The bleeding occurs every 10 days and lasts 7 to 10 days. She is not currently bleeding. Before the bleeding began, she had not had a menstrual period for 4 months. She has a history of six episodes of amenorrhea, each lasting 4 months during the past 2 years; previous treatment with oral progestin induced withdrawal bleeding. Her last Pap smear 1 year ago showed no abnormalities. She currently takes no medications. She is 163 cm (5 ft 4 in) tall and weighs 86 kg (190 lb); BMI is 33 kg/m 2. Examination shows darkened skin with a velvety texture over the base of the neck, axillae, and perineum. Coarse hair is noted over the upper lip and chin. There is no thyromegaly. No discharge is expressed on palpation of the nipples. Central obesity is noted. Coarse hair extends from the umbilicus to the pubic area; the pubic hair has a diamond-shaped pattern. Which of the following is the most appropriate next step in diagnosis? endometrial biopsy

Educational Objective: Abnormal uterine bleeding may be caused by neoplastic, structural, coagulopathic, infectious, endocrine, or iatrogenic sources. An important cause is endometrial cancer, the risk for which is increased with obesity, polycystic ovary syndrome, prolonged estrogen exposure, early menarche or late menopause, nulliparity, advanced age, and family history. Appropriate evaluation includes an endometrial biopsy. Treatment consists of a hysterectomy with bilateral salpingo-oophorectomy.

Two weeks after undergoing uncomplicated emergency appendectomy, a 62-year-old woman comes to the physician for a follow-up examination. Recovery has been uncomplicated. A CT scan of the abdomen with contrast prior to the operation also showed a 1.5-cm left adrenal mass with a smooth border and homogeneous uptake. She has hypertension. Her medications are hydrochlorothiazide, amlodipine, and fiber supplementation. Vital signs are within normallimits. Examination shows a well-healing surgical scar over the abdomen. No other abnormalities are noted. Hormonal testing of adrenal function shows no abnormalities. Which of the following is the most likely diagnosis?

Educational Objective: Adrenal adenomas are benign tumors that originate in the adrenal glands, typically forming in the cortex, and are characterized by their ability to produce hormones, particularly cortisol. They are typically small, measuring less than 2 cm in diameter. On CT scan, adrenal adenomas appear smooth with a well-defined border, do not infiltrate surrounding structure, and enhance homogeneously with contrast. Adrenal adenomas that produce cortisol can cause Cushing syndrome. Adrenal adenomas that produce aldosterone can cause Conn syndrome.

A 52-year-old woman with long-standing alcohol use disorder is brought to the emergency department because of a 2-day history of severe abdominal cramps, fever, nausea, vomiting, and tremulousness. She has drunk 1 L of vodka daily during the past week; her last glass of vodka was 2 days ago. On arrival, the patient is mildly confused and is unable to provide further history. She is oriented to person and place but not to time. Her temperature is 37.7°C (99.9°F), pulse is 110/min, respirations are 18/min, and blood pressure is 152/92 mm Hg. Examination shows marked scleral icterus. Abdominal examination shows tenderness to palpation over the right upper quadrant. The liver span is 14 cm. There is no fluid wave or asterixis.

Educational Objective: Alcohol withdrawal typically presents with tremors, anxiety, restlessness, headache, nausea, and diaphoresis. It can be complicated by seizures, alcoholic hallucinosis, and delirium tremens. It is treated with benzodiazepines.

A 17-year-old girl comes to the office for health counseling 2 days after an endocervical swab obtained during her last pelvic examination was positive for Neisseria gonorrhoeae by nucleic acid amplification test. She has had unprotected sexual intercourse with several male partners; one of her partners was an intravenous drug user. She refuses HIV testing. She insists that her test results be kept strictly confidential. Which of the following is the most appropriate next step?

Educational Objective: All states in the United States have requirements for the mandatory reporting of particular sexually transmitted infections (STls) to state and local health departments. Timely reporting of STls to appropriate health officials is important in partner notification and reducing the incidence and spread of infection. While certain states have more stringent reporting requirements for other infections, HIV, syphilis, gonorrhea, chlamydia, and chancroid are mandatorily notifiable diseases in every state.

A 27-year-old woman comes to the physician because of a 3-week history of severe rectal pain with defecation. During this time, she also has noted occasional blood on the toilet tissue after defecation. She has not had constipation, abdominal pain, fever, nausea, or vomiting. She has no history of serious illness. Her only medication is an oral contraceptive. She does not smoke cigarettes or drink alcohol. She has had three lifetime sexual partners. She is married and monogamous with her husband of 1 year. Her last Pap smear was 2 years ago and showed no abnormalities. She worries that her current symptoms may be affecting her performance at work as a pharmaceutical representative. She maintains a healthy diet and exercises regularly. Vital signs are within normal limits. Abdominal examination shows no abnormalities. On rectal examination, there is tenderness; no masses are seen or palpated. Which of the following is the most likely diagnosis?

Educational Objective: Anal fissures commonly present with rectal pain, particularly with defecation, and bleeding because of a tear in anal tissue. Pain can occur from irritation of the tear itself or because of spasm of the internal sphincter. Causes of primary anal fissures include constipation, diarrhea, and vaginal delivery, although secondary fissures can occur in the setting of systemic illnesses, such as sarcoidosis, inflammatory bowel disease, or HIV infection. The initial management of anal fissures includes the prevention or treatment of constipation, topical analgesics, and topical vasodilators. In this case, the most likely diagnosis is anal fissure based on the timing of this patient's symptoms with defecation as well as blood on toilet tissue in the absence of other systemic symptoms.

A 12-month-old girl is brought to the physician 6 hours after the onset of swelling of the lips and an itchy rash over her face and hands; she is drooling and has vomited twice during this period. Her mother says that her daughter had a similar rash once before, but it resolved spontaneously within 1 hour. The girl is breast-fed and eats some table foods. Prior to her symptoms today, she ate ice cream for the first time. She appears alert and active. Examination shows multiple erythematous macular lesions over the face, neck, hands, and wrists. Bilateral end-expiratory wheezing is heard on auscultation. Which of the following is most likely to confirm the diagnosis?

Educational Objective: Anaphylaxis is an lgE-mediated hypersensitivity reaction that leads to extensive degranulation of mast cells and basophils, which results in acute multisystem inflammation and vasodilation. Symptoms include bronchospasm with associated dyspnea or wheezing, urticaria, flushing, nausea and emesis, edematous lips and tongue, and hypotension with tachycardia. Treatment begins with urgent administration of epinephrine, followed by antihistamines, bronchodilators, glucocorticoids, and fluids. Following acute treatment, radioallergosorbent testing can be used to identify triggers.

A 57-year-old man comes to the physician for a routine examination. He feels well. He has mild hypertension and type 2 diabetes mellitus. He underwent an uncomplicated total right knee arthroplasty 2 years ago. Repair of a chipped molar tooth is scheduled in 1 week, and the patient requests antibiotics to prevent infection around his prosthetic joint. General health screening measures are up-to-date. The patient is allergic to penicillin. Current medications arehydrochlorothiazide, enalapril, and insulin. His temperature is 37°C (98.6°F), pulse is 85/min, respirations are 12/min, and blood pressure is 145/84 mm Hg. Examination shows a well-healed scar over the right knee. Which of the following is the most appropriate next step in management?

Educational Objective: Antibiotic prophylaxis is of uncertain benefit prior to dental procedures. Current guidelines recommend against routine antibiotic prophylaxis in patients for prevention of prosthetic joint infection. Unnecessary use of antibiotics preoperatively is associated with adverse effects, antibiotic resistance, and unnecessary medical costs. The best option for a patient concerned about the risk for developing a joint infection following a dental procedure is reassurance.

A 57-year-old woman comes to the physician because of a 2-week history of a tender lump in her right armpit. The lump has not changed in size during this period. She has no history of serious illness and takes no medications. Ten months ago, annual examination, Pap smear, and mammography showed no abnormalities. There is no family history of cancer. Examination shows a 3-cm, firm, round mass in the right axilla immediately lateral to the pectoralis major muscle. There is no associated axillary lymphadenopathy. The remainder of the examination, including examination of the breasts, shows no abnormalities. Which of the following is the most appropriate next step in management?

Educational Objective: Breast cancer is the most common nondermatologic cancer in patients assigned female at birth in the United States. It commonly presents with a breast mass that is irregular, firm, and adherent, with overlying skin changes or associated lymphadenopathy. Evaluation of a palpable breast mass includes diagnostic imaging with either ultrasonography, if under age 35 years, or mammography, if over age 35 years. If the palpable lesion is not visible on the first modality, a subsequent modality should be used.

A42-year-old man comes to the physician because of a 6-month history of cough productive of thick, white, mucopurulent sputum. The cough frequently keeps him awake at night. He has not had fever or chills but has had an unintentional 4.5-kg (10-lb) weight loss during the past 3 years. Each winter during the past 15 years, he has had recurrent episodes of bronchitis treated with antibiotic therapy. During childhood, he had four episodes of "double pneumonia." He emigrated from the Philippines 1Oyears ago. He smoked one-half pack of cigarettes daily for 5 years but quit 15 years ago. He is not in distress. He is 183 cm (6 ft) tall and weighs 68 kg (150 lb); BMI is 20 kg/m2. His pulse is 68/min, respirations are 14/min, and blood pressure is 132/81 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 95%. On pulmonary examination, coarse rhonchi are heard best at the left lung base. There is bilateral inspiratory and faint expiratory wheezing in both lung bases. Cardiac examination shows no abnormalities. A chest x-ray is shown. Which of the following is the greatest predisposing risk factor for this patient's condition?

Educational Objective: Bronchiectasis refers to irreversible dilatation and thickening of the bronchi that results from recurrent infections and chronic inflammation. It is associated with conditions that result in impaired mucociliary clearance and immune dysfunction.

A 57-year-old woman comes to the emergency department because of a 1-day history of cough productive of blood-tinged sputum. She notes that since this morning, she has coughed up approximately 1 cup of bright red blood. She has not had fever or chills. She has a 4-year history of postnasal drip and nasal congestion. She has smoked one pack of cigarettes daily for 40 years. Her pulse is 100/min, respirations are 22/min, and blood pressure is 130/80 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 92%. Diffuse wheezes are heard at the left lung base. An x-ray of the chest shows loss of volume in the left hemithorax. Which of the following is the most likely diagnosis?Endobronchial lesion

Educational Objective: Bronchogenic carcinoma is a leading cause of cancer-related death in the United States and is divided into small cell and non-small cell carcinoma. It commonly presents with cough, weight loss, hemoptysis, and signs of bronchial obstruction. Early diagnosis is paramount as the prognosis of advanced stage disease is poor.

A 6-year-old boy is brought to the emergency department by his parents because of a 2-day history of fever, sore throat, a rapidly spreading rash, and decreased oral intake. During the past 12 hours, he has refused to eat or drink and has not voided. Medical history is remarkable for a 3-day hospitalization at age 2 months for enterovirus meningitis. The patient currently receives no medications and vaccinations are up-to-date. He appears uncomfortable. He is at the 60th percentile for height and 50th percentile for weight; BMI is at the 40th percentile. Temperature is 39.0°C (102.2°F), pulse is 100/min, respirations are 18/min, and blood pressure is 110/70 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 98%. Physical examination discloses oral lesions and dry mucous membranes. There is a blanching rash over the upper and lower extremities and buttocks. The lesions appear as shown in the photographs. Cardiopulmonary examination discloses no abnormalities. Abdominal examination discloses no tenderness or hepatosplenomegaly. Which of the following is the most appropriate initial diagnostic study?

Educational Objective: Coxsackievirus is transmitted via oral secretions or feces. Coxsackievirus group A infection causes hand-foot-and-mouth disease and herpangina. Both are generally benign and self-limiting and do not require further diagnostic workup.

A42-year-old man is brought to the emergency department because of a 6-hour history of moderate diffuse headache, blurred vision, difficulty concentrating, moderate back pain, and tingling of his hands and feet. He made three dives during 4 hours to depths of 90 feet. His symptoms began while he returned to the dock after 4 hours in the water. He has no history of serious illness and takes no medications. He has smoked one pack of cigarettes daily for 20 years and drinks four to six 12-oz beers daily. His pulse is 100/min; other vital signs are within normal limits. Physical examination shows no abnormalities. On neurologic examination, cranial nerves are intact. Muscle strength is 5/5 in the upper extremities and 4/5 in the lower extremities. Deep tendon reflexes are 1+ in the upper extremities and 3+ in the lower extremities. Babinski sign is present bilaterally. Sensation is normal over the hands. Proprioception and sensation to pinprick, vibration, and temperature are decreased over the lower extremities. Cognition is intact. After obtaining results of a complete blood count, complete metabolic panel, and ECG, which of the following is the most appropriate next step in management?A )

Educational Objective: Decompression sickness (DCS) occurs when the body undergoes a decrease in atmospheric pressure, resulting in formation of bubbles of dissolved gas within the blood and other tissues. Signs and symptoms include rash, pruritus, joint and abdominal pain, and neurologic and central nervous system symptoms such as obtundation, stroke, or spinal infarction in severe cases. DCS is most commonly encountered in divers using self-contained underwater breathing apparatus (scuba) systems. The treatment of DCS is supportive with immediate recompression with hyperbaric oxygen, as well as analgesia and intravenous fluids.

45. A 67-year-old woman has had recurrent episodes of pain and stiffness in the hands and knees over the past year; the e p ~ s occur almost daily. She has had no fevers or chills. A photograph of the hands is shown. Which of the following is the most likely diagnosis?A) Degenerativeosteoarthritis

Educational Objective: Degenerative osteoarthritis is a noninflammatory arthropathy that occurs secondary to deterioration of articular cartilage. It typically occurs in older patients and may affect any joint. In the hands, the distal interphalangeal joint is most affected with possible development of firm bony nodes in the distal or interphalangeal joint known as Heberden or Bouchard nodes, respectively. First-line treatment is with acetaminophen, with additional treatment options including nonsteroidal anti-inflammatory drugs, intra-articular injections (eg, cortisone), and joint replacement surgery for severe or refractory cases.

A 3-year-old girl is brought for a well-child examination. Her mother notes that she can ascend but not descend stairs with alternating feet. She is at the 10th percentile for height and 25th percentile for weight. She copies a cross but not a square. She can count three objects correctly. She is able to stand, but not hop, on one foot. She speaks in five-word sentences. During the examination, she shares a toy with her sibling. Which of the following is the most accurate assessment of her development?

Educational Objective: Developmental milestones are categorized into fine motor, gross motor, social development, and language findings. In a 3-year-old child, expected abilities include the ability to ride a tricycle or ascend stairs with alternating legs, use two- to three-word sentences or use greater than 300 words, and draw a circle.

One day after undergoing resection of a craniopharyngioma, a 42-year-old woman has confusion, lethargy, and increased thirst and urination. She has no other history of serious illness. Her only medication is morphine for pain. She does not smoke cigarettes, drink alcohol, or use illicit drugs. Her temperature is 36.5°C (97.7°F), pulse is 80/min, respirations are 14/min, and blood pressure is 130/80 mm Hg. On neurologic examination, the patient is alert and oriented to person and place but not to date. Speech is slowed. The remainder of the examination shows no abnormalities. Serum studies show:

Educational Objective: Diabetes insipidus can be either central or peripheral. Central diabetes insipidus is caused by a lack of ADH (vasopressin) secretion while peripheral diabetes insipidus is caused by a lack of responsiveness of the kidney tubules to ADH. Patients will present with symptoms of excess urination, thirst, and potentially neurologic changes because of resultant hypernatremia. Treatment depends on the cause but generally will comprise of ADH antagonists or saltrestriction.

A 72-year-old woman comes to the physician because of a 6-week history of intermittent rectal bleeding with bowel movements. She underwent a hysterectomy at the age of 42 years for leiomyomata uteri. She has hypertension treated with amlodipine. Rectal examination shows several small external hemorrhoids. Her hematocrit is 31 %. Which of the following is the most appropriate next step in management?

Educational Objective: Diagnosis and treatment of lower gastrointestinal bleeding requires an initial colonoscopy; this procedure enables visualization, biopsy, cautery, and other interventions. There are many causes of gastrointestinal bleeding, including neoplasia, diverticulosis, arteriovenous malformations, and angiodysplasia. Colonoscopy allows for the ability to narrow the differential diagnosis and in many cases identify the source, while also facilitating treatment of any identified lesions.

A previously healthy 22-year-old woman comes to the physician because of a 2-month history of intermittent moderate headache. She is otherwise asymptomatic. She takes no medications. She has smoked one pack of cigarettes daily for 4 years. Her temperature is 37°C (98.6°F), pulse is 64/min, respirations are 18/min, and blood pressure is 156/90 mm Hg. Cardiopulmonary examination shows no abnormalities. On abdominal examination, a bruit is heard in the left upper quadrant. The remainder of the examination shows no abnormalities. Serum studies show:

Educational Objective: Fibromuscular dysplasia is a common cause of renal artery stenosis in young patients. Due to activation of the renin-angiotensin-aldosterone system and high concentrations of angiotensin 11, secondary hypertension develops.

A 67-year-old man comes to the physician because of a 4-month history of increasingly severe, constant epigastric pain. He says that he feels full after eating only small amounts of food. During the past 6 months, he has had an8.6-kg (19-lb) weight loss. He has osteoarthritis treated with ibuprofen as needed and a 15-year history of type 2 diabetes mellitus treated with insulin. He has smoked two packs of cigarettes daily for 50 years and drinks two beers daily. He is 178 cm (5 ft 10 in) tall and now weighs 67 kg (148 lb); BMI is 21 kg/m2. His pulse is 68/min, respirations are 16/min, and blood pressure is 138/72 mm Hg. Abdominal examination shows epigastric tenderness. Rectal examination shows brown stool. Test of the stool for occult blood is negative. His hemoglobin concentration is 12 g/dl, and mean corpuscular volume is 70 μm 3. Which of the following is the most appropriate initial step in diagnosis?

Educational Objective: Gastric cancer typically presents with weight loss, early satiety, and epigastric pain. The most appropriate initial step for diagnosis of gastric cancer is upper endoscopy with tissue biopsy of any suspicious lesions.

A previously healthy 3-year-old boy is brought to the physician by his mother because of a 3-week history of foul-smelling progressive diarrhea and gas. He has not had fever. He began attending day care 2 months ago. Vital signs are within normal limits. Examination shows dry mucous membranes and mild abdominal distention. Which of the following is the most likely causal organism?Giardia lamblia

Educational Objective: Giardia lamblia is a flagellated, parasitic organism that causes giardiasis. It presents with persistent diarrhea that is foul-smelling and fatty, abdominal pain, bloating, and cramping. Weight loss will also occur as a result of small bowel parasitic overgrowth and the resultant malabsorption of fats and carbohydrates. Metronidazole is the first-line treatment.

A 23-year-old woman comes to the emergency department because of a 5-day history of a red wound that leaks pus on her inner left arm. She also has a 1-month history of mild headaches. Her only medication is ibuprofen. She uses intravenous heroin and smokes marijuana. She has been sexually active with 10 male partners during the past 2 months; her partners have not used condoms. Her temperature is 38.6°C (101.5°F), pulse is 100/min, respirations are 22/min, and blood pressure is 110/70 mm Hg. Cardiopulmonary examination shows no abnormalities. There is a 3 x 3-cm, erythematous, tender, fluctuant, subcutaneous mass over the left antecubital fossa. Her hemoglobin concentration is 10.8 g/dL, hematocrit is 32%, and leukocyte count is 700/mm3 (60% segmented neutrophils, 20% bands, and 20% lymphocytes). Which of the following is the most likely cause of this patient's laboratory findings?

Educational Objective: HIV infection commonly presents with diffuse lymphadenopathy, diarrhea, sore throat, malaise, fever, and weight loss. Patients may also present with opportunistic infections or may be entirely asymptomatic. Diagnosis in patients who do not meet classical risk criteria requires a high degree of clinical suspicion. Testing with a fourth-generation antigen/antibody test in addition to assessment of the HIV viral load is requisite.

A 4-year-old boy is brought to the emergency department by his mother after he refused to walk or bear weight on his left leg this morning. She says he has been irritable during the past 3 days. He has a 3-month history of episodes of moderate pain in his shoulders and ankles, but the pain has not been as severe as his current symptom. His mother says he bruises easily. He has not had recent trauma or fever. He was born at term by spontaneous vaginal delivery following an uncomplicated pregnancy. He walked at the age of 11 months. He attends preschool. He is at the 70th percentile for height and 60th percentile for weight. Vital signs are within normal limits. There is no gingival bleeding, and the teeth are intact. There is a deep ecchymosis over the anterior aspect of the left thigh; the skin otherwise appears normal. The patient is unable to extend the left knee because of pain. Laboratory studies are most likely to show which of the following sets of findings in this patient?

Educational Objective: Hemophilia A results from a genetically inherited deficiency in factor VIII synthesis or activity. Patients present with easy bruising and hemorrhage into muscle and joints. Laboratory studies show an increased partial thromboplastin time, but a normal prothrombin time. Treatment is with recombinant factor VIII.

A 32-year-old man comes to the emergency department because of a 2-week history of progressive shortness of breath, nonproductive cough, and low-grade fever. He has not had night sweats or change in weight. He has no history of serious illness and takes no medications. Over the past 6 years, he has been sexually active with 10 male partners; he uses condoms inconsistently. He does not smoke or drink alcohol. He appears anxious. His temperature is37.?°C (99.8°F), pulse is 96/min, respirations are 28/min, and blood pressure is 120/75 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 82%. Jugular venous pressure is 6 cm H p . Diffuse crackles are heard bilaterally. The remainder of the examination shows no abnormalities. An x-ray of the chest shows bilateral interstitial infiltrates. A silver stain of the sputum is positive. Antibiotic therapy is begun. Which of the following is the most likely cause of thispatient's hypoxemia?

Educational Objective: Hypoxemia induced by pneumonia is due to the decreased diffusion capacity of alveoli or ventilation perfusion mismatch. This is a result of both inflammation and infiltration of the tissues, creating poor oxygen transfer. Treatment for patients with hypoxemia due to pneumonia is supplemental oxygen and treatment of the underlying infection.

A 57-year-old man, who is an accountant, comes to the physician because of progressive shortness of breath during the past 6 months. He says he has difficulty breathing after walking more than one city block and when walking up one flight of stairs. He reports that during these episodes, he feels that he needs to breathe rapidly. He also has had a dry cough. He has not had chest pain, diaphoresis, nocturnal symptoms, or worsening of the symptoms when lying down. He has a 5-year history of hypertension treated with enalapril and hydrochlorothiazide. He has never smoked cigarettes. His temperature is 37°C (98.6°F), pulse is 89/min, respirations are 18/min, and blood pressure is 145/82 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 90%. Crackles are heard at both lung bases. A high-resolution CT scan of the chest shows a reticulogranular appearance at the bases bilaterally with minimal fibrosis. Pulmonary function tests show moderately severe decreased diffusion capacity. Examination of bronchoalveolar lavage fluid shows many segmented neutrophils that are negative for bacteria, fungi, and acid-fast bacilli. In addition to supplemental oxygen, administration of which of the

Educational Objective: Idiopathic pulmonary fibrosis is a chronic, progressive lung disease characterized by the scarring of the lung parenchyma. Scarring is caused by overactivation of fibroblasts in the lung tissue. This results in a restrictive pattern of disease. Prognosis is generally poor. Treatment includes oxygen therapy, corticosteroids, and immunomodulators.

A 27-year-old white man comes to the physician because of increasing fatigue for 3 weeks. He has a 5-year history of heavy alcohol intake and currently drinks 10 oz of alcohol daily. Over the past year, he has had several episodes of hematemesis and associated melenic stools. Examination shows palmar erythema, spider angiomata, and mild splenomegaly. His hemoglobin concentration is 7 g/dl. A blood smear shows hypochromic microcytic erythrocytes and increased numbers of platelets. Serum studies are most likely to show which of the following?

Educational Objective: Iron deficiency anemia most commonly results from chronic gastrointestinal blood loss but can also be seen in patients with malnutrition and chronic alcohol use. Patients with iron deficiency anemia will have low concentrations of serum iron, transferrin saturation, and ferritin. Blood smear will show a microcytic, hypochromic anemia.

A 28-year-old woman comes to the physician because of a 4-month history of mild lower abdominal pain that is relieved with defecation. During this time, she also has had nonfatty, nongreasy diarrhea with mucus but no blood. She does not have bowel movements during the night. She is otherwise asymptomatic. She has generalized anxiety disorder treated with citalopram. There is no family history of colon cancer. The patient's vital signs are within normal limits. Theabdomen is not distended or tender. There are no masses, and bowel sounds are normal. Results of a complete blood count are within the reference ranges. Results of serum antiendomysial lgA and anti-tissue transglutaminase antibody testing are negative. Tests of the stool for occult blood, ova, parasites, and leukocytes are negative. Sigmoidoscopy shows no abnormalities. Which of the following is the most appropriate next step in management?

Educational Objective: Irritable bowel syndrome (IBS) is characterized by abdominal pain and a change in stool appearance or frequency. In patients with IBS and diarrhea, dietary changes and symptom control with loperamide therapy are the first steps in management. Features that are suggestive of underlying organic pathology rather than IBS include the presence of occult blood or melena, nocturnal diarrhea, worsening abdominal pain, weight loss, or a family history of inflammatory bowel disease or colon cancer.

A 67-year-old woman comes to the physician because of a 6-month history of increasing vaginal pain and itching. She has not had any pelvic pain or vaginal discharge. Menopause occurred at the age of 51 years. She has no history of serious illness and takes no medications. A photograph of the vulva is shown. The remainder of the examination, including pelvic examination, shows no abnormalities. Which of the following is the most likely diagnosis?lichen sclerosis

Educational Objective: Lichen sclerosus most commonly presents in patients who are postmenopausal with vulvar pain and pruritus associated with thinning and fibrosis of the genital and perianal skin. Physical examination will show pruritic white plaques, occasionally with ulcerations, and thin, fibrosed skin. Advanced disease can cause narrowing of the introitus and loss of the separation between the labia majora and minora. Diagnosis is confirmed with biopsy.

A 16-year-old girl is brought to the office by her mother because of a 1-year history of increasing facial hair growth and acne. Menses have occurred at irregular 60- to 90-day intervals since menarche at the age of 12 years. She takes no medications. She is 168 cm (5 ft 6 in) tall and weighs 70 kg (155 lb); BMI is 25 kg/m2. Examination shows acne vulgaris over the forehead and chin. Her Ferriman-Gallwey score for hair growth is 10 (N<8). Her serum testosterone concentration is 45 ng/dl (N<5-40). Results of other serum studies, including thyroid-stimulating hormone, prolactin, and dehydroepiandrosterone sulfate concentrations, are within the reference ranges. Which of the following is the most likely cause of this patient's condition?

Educational Objective: Polycystic ovarian syndrome presents with menstrual irregularities, signs of androgen excess, obesity, insulin resistance, and polycystic ovaries on ultrasonography. It is associated with increased concentrations of testosterone but normal concentrations of dehydroepiandrosterone sulfate. Treatment includes weight loss and combined oral contraceptives for menstrual regulation, and antihyperglycemic medications or insulin for the management of diabetes mellitus, if diagnosed.

Six weeks after undergoing triple coronary artery bypass grafting after suffering an acute myocardial infarction, a 57-year-old man comes to the office with his wife for a follow-up examination. Since the surgery, the patient has had left leg pain and numbness and a 9-kg (20-lb) weight loss. He reports that he has not been sleeping well and has had an intermittent cough. His energy has been decreased and he has lost interest in his usual activities. He has not had chest pain. A low-impact exercise program was prescribed at the time of discharge. The patient's wife says that he has not maintained the suggested exercise program, stating that he was too tired. Medications include atenolol, atorvastatin, and 81-mg aspirin daily. He is 173 cm (5 ft 8 in) tall and weighs 91 kg (200 lb); BMI is 30 kg/m 2. Vital signs are temperature 37.0°C (98.6°F), pulse 62/min, respirations 14/min, and blood pressure 140/80 mm Hg. Physical examination discloses well-healed surgical incisions. Total serum cholesterol concentration is 180 mg/dl, and fasting blood glucose concentration is 128 mg/dl. Which of the following is the most appropriate change in the patient's therapy?

Educational Objective: Major depressive disorder includes 2 or more weeks of five of the following symptoms: depressed mood, anhedonia, guilt or worthlessness, difficulty concentrating, psychomotor delay, suicidal thoughts, and/or neurovegetative symptoms (eg, decreased energy, sleep disturbance, appetite disturbance). Psychological symptoms such as a sad and tearful mood, decreased interest, and hopelessness can distinguish symptoms of major depressive disorder from symptoms of systemic medical illness. Selective serotonin reuptake inhibitors, such as sertraline, are generally first-line treatments, especially for patients with heart disease, given their benign cardiac adverse effect profiles.

A study is conducted to compare the safety of primary closure of the colon with temporary colostomy in patients with penetrating injuries of the colon. The study is conducted over a 36-month period in a single institution. All patients between the ages of 18 and 65 years admitted with penetrating injuries of the colon are enrolled in the study; they are assigned to one of two study groups, depending on which procedure their surgeon chose, and observed until discharge from the hospital. The complication rate for the 38 patients who underwent primary closure of the colon is 14%. The complication rate for the 37 patients who underwent temporary colostomy is 16%. The authors conclude that primary closure of colon injuries has the same level of safety as temporary colostomy in adults. Which of the following raises the most concern about this conclusion?

Educational Objective: Matching is an important process in clinical trial design that is intended to produce an equal balance between the study groups of variables that may lead to confounding. Confounding variables influence both the independent and dependent variables and can lead to false associations if the confounding variable is not evenly distributed in both study groups. A good study design will proactively identify potential confounders prior to randomization.

A 24-year-old woman comes to the physician because of a 3-day history of progressive right-sided weakness and numbness. One year ago while traveling overseas, she had loss of vision in the left eye that developed gradually during the course of 1 week, persisted for 1 month, and resolved gradually and spontaneously during the following 3 weeks. At its worst, her vision in the left eye was severely blurred and colors appeared washed out. Her vision recovered completely, and she did not see a physician. She has not had similar symptoms since that time. She has no other history of serious illness and takes no medications. Examination shows mild weakness of the right lower aspect of the face. Muscle strength is 4/5 in the right extremities. Sensation to light touch is mildly decreased over the right side of the face and body. Examination shows no abnormalities on the left. An MRI of the brain is shown. Which of the following is the most appropriate pharmacotherapy to decrease the recurrence of similar symptoms in this patient?

Educational Objective: Multiple sclerosis (MS) is a progressive autoimmune demyelinating disease that affects neurons of the central nervous system, resulting in neurologic symptoms that are separated in time and location. Optic neuritis is a common initial manifestation and typically presents with poor visual acuity and a consequent afferent pupillary defect on physical examination. Treatment of MS includes corticosteroids to decrease the duration of acute flares and immune- modulating therapies (eg, subcutaneous glatiramer) to prevent future recurrences.

A 15-month-old boy is admitted to the hospital because of a 2-day history of temperatures to 39.5°C (103.1 °F) and a swollen red mass on the right side of the neck. He has a 1-year history of failure to thrive, recurrent suppurative skin infections, and two prior episodes of lymphadenitis. At the age of 9 months, he was hospitalized for a lung abscess secondary to Staphylococcus aureus infection. He has had three hospital admissions for two episodes of staphylococcal pneumonia with abscesses and one episode of osteomyelitis. He currently receives no medications. He is at the 3rd percentile for height and 5th percentile for weight. His temperature is 39.5°C (103.1°F}, pulse is 100/min and regular, respirations are 30/min, and blood pressure is 105/55 mm Hg. Examination shows no dysmorphic features. There is a 3 x 4-cm erythematous, indurated, warm, tender nodule on the right side of the neck. No murmurs are heard on cardiac examination. On abdominal examination, the liver edge is palpated 4 cm below the right costal margin. Which of the following is most likely to confirm the cause of recurrent suppurative infections in this patient?

Educational Objective: NADPH oxidase is necessary for the formation of reactive oxygen species in phagocytes, which allows for bactericidal activity. Mutations in the proteins that make up the NADPH oxidase complex result in chronic granulomatous disease, typically characterized by recurrent pyogenic bacterial infections. Diagnosis is confirmed with neutrophil oxidative burst tests, either a dihydrorhodamine test or a nitroblue tetrazolium reduction test.

A 35-year-old man comes to the physician for a health maintenance examination. He has no history of serious illness and takes no medications. His parents have essential hypertension. The patient is 180 cm (5 ft 11 in) tall and weighs 72 kg (160 lb); BMI is 22 kg/m 2. His pulse is 72/min and regular, and blood pressure is 155/95 mm Hg. Repeat blood pressure measurement is 159/98 mm Hg. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate next step in management?

Educational Objective: Stage 1 hypertension is defined as a systolic blood pressure greater than 130 mm Hg or a diastolic blood pressure greater than 80 mm Hg, obtained with both in-office and at-home measurements, or with serial in-office measurements over a period of weeks to months. Risk factors for primary hypertension include advancing age, obesity, sedentary lifestyle, smoking, genetic factors, high-sodium diet, excessive alcoholic beverage consumption, and insufficient sleep. Once confirmed, lifestyle modifications should be encouraged, and an appropriate antihypertensive agent should be initiated.

A 70-year-old woman is brought to the emergency department from the nursing care facility where she resides, because of a 2-day history of low-grade fever, decreased appetite, and lethargy. She has type 2 diabetes mellitus and cognitive impairment. Her only medication is metformin. The patient is drowsy and responds to questions with inconsistent answers. She is 152 cm (5 ft) tall and weighs 64 kg (140 lb); BMI is 27 kg/m2. Her temperature is 38.0°C (100.4°F), pulse is 90/min, respirations are 20/min, and blood pressure is 100/60 mm Hg. Cardiopulmonary examination shows no abnormalities. Examination of the left lower extremity shows a rapidly expanding area of red, shiny skin on the shin with a small fluid-filled bulla. The area is exquisitely tender and warm to the touch. In addition to intravenous antibiotic therapy, which of the following is the most appropriate next step in management...) Begin surgical exploration in the operating room

Educational Objective: Necrotizing fasciitis may be caused by Staphylococcus aureus, Streptococcal spp., Clostridium spp., or Bacteroides spp. infection following cellulitis, trauma, or invasive procedure. It is characterized by tissue necrosis, may be associated with sepsis, and has a high morbidity and mortality. All patients with suspected necrotizing fasciitis must be aggressively treated with operative tissue debridement and empiric intravenous antibiotics. During tissue debridement, tissue cultures should be obtained to inform subsequent targeted antibiotic therapy.

A 77-year-old man is brought to the physician by his wife because of a 3-week history of confusion, daytime sleepiness, and frequent falls. He appears lethargic but is arousable. Neurologic examination shows no focal findings. On mental status examination, he is oriented to person but not to place or time. Short-term memory is decreased. Which of the following is the most likely diagnosis?E) Subdural hematoma

Educational Objective: Older patients are at risk for cerebral atrophy, which causes traction on bridging cortical veins, such that minor trauma can result in venous injury leading to a subdural hematoma. Patients with subdural hematoma commonly present with the acute or subacute focal neurologic deficits and confusion. When mass effect is present or at risk for developing, surgical interventions, such as decompressive burr holes or a craniotomy, may be indicated to evacuate the hematoma.

A 34-year-old woman, gravida 3, para 2, at 36 weeks' gestation comes to the office for her first prenatal visit. She has received no prenatal care, because she did not have health insurance until recently. After her last pregnancy 2 years ago, she was diagnosed with hypertension, which has been well controlled with lisinopril since that time. She takes no other medications and has no known allergies. Her pulse is 88/min, respirations are 18/min, and blood pressure is 130/80 mm Hg. Fundal height is 33 cm. Fetal movement is noted. This patient is at greatest risk for which of the following pregnancy complications?

Educational Objective: Oligohydramnios describes an inadequate amount of amniotic fluid or a low amniotic fluid index. Oligohydramnios leads to impaired lung development in the fetus, physical deformities or growth restriction of the newborn as a result of amniotic sac constriction, and umbilical cord compression leading to variable decelerations on fetal heart rate monitoring. Lisinopril is a known teratogen in pregnancy and can cause fetal hypotension with consequent kidney injury and oligo- or anuria, which leads to oligohydramnios. Other causes include prelabor rupture of membranes, fetal infection, post-term pregnancy, uteroplacental insufficiency, and congenital malformations of the fetal genitourinary tract.

One day after undergoing elective left total hip replacement, a hospitalized 75-year-old woman is somnolent and has slow, shallow breathing. She has had severe postoperative pain and has been receiving intravenous morphine. She has hypertension and gastroesophageal reflux disease. Her other medications are amlodipine, omeprazole, and enoxaparin. Temperature is 37.3°C (99.1 °F), pulse is 64/min, respirations are 8/min, and blood pressure is 110/62 mm Hg. Pulseoximetry on room air shows an oxygen saturation of 88%. Examination shows a clean, dry surgical incision without drainage or erythema. Cardiopulmonary examination shows no abnormalities. There is no edema of the lower extremities. Neurologic examination shows no focal findings. Which of the following is the most appropriate next step in management?Administration of naloxone

Educational Objective: Opioid overdoses are characterized by miosis, altered mental status, and respiratory depression presenting as a decreased respiratory rate, apnea, and hypoxia. Naloxone is a short-acting opioid receptor antagonist that reverses the respiratory depression caused by opioid overdose and should be administered emergently to patients presenting with altered mental status and respiratory depression.

A 72-year-old man with hypertension comes to the office because of a 7-month history of postvoid dribbling and urinary incontinence associated with urgent, unexpected sensations of the need to urinate. His medications are lisinopril and aspirin. His blood pressure is 160/80 mm Hg. Examination shows normal external genitalia and a moderately enlarged, firm prostate. His postvoid residual volume is 200 ml. Which of the following is the most likely cause of this patient's urinary incontinence?obstruction

Educational Objective: Overflow incontinence is caused by underactive or flaccid detrusor muscles or bladder outlet obstruction and is characterized by chronic urinary retention and a chronically distended bladder. A common cause of overflow incontinence in men is benign prostatic hyperplasia.

Comprehensive Clinical Science Self-Assessment A 37-year-old woman comes to the physician for a routine health maintenance examination. She feels well. She has no history of serious illness and no known allergies. She takes no medications. On examination, a 1.5-cm nodule over the right aspect of the thyroid gland is palpated. There is no lymphadenopathy. The remainder of the examination shows no abnormalities. In addition to measurement of serum thyroid-stimulating hormone concentration, which of the following is the most appropriate next step in diagnosis?

Educational Objective: Palpable thyroid masses are a common incidental finding on physical examination and imaging. Diagnostic workup is necessary to exclude malignancy, and all patients should have their TSH concentration checked, and ultrasonography of the thyroid gland performed. Fine-needle aspiration biopsy is indicated if the TSH is normal or increased, the patient has risk factors for thyroid malignancy, or the nodule has concerning ultrasonographic features.

A 27-year-old man is brought to the emergency department (ED) by his fiancee 30 minutes after the sudden onset of shortness of breath, chest tightness, palpitations, and severe, generalized discomfort. This is the patient's third visit to the ED during the past month for episodes of similar symptoms; each time, ECGs showed only sinus tachycardia, and he was discharged after evaluation disclosed no abnormalities. Today, he says he has been "excessively worried" thathe will have another episode. He has hyperlipidemia treated with atorvastatin. Two months ago, he began bupropion for smoking cessation. He previously drank five 12-oz beers weekly; two weeks ago, he stopped drinking beer altogether in an effort to decrease the frequency of these episodes. He smoked one pack of cigarettes daily for 6 years but quit 5 weeks ago. He appears anxious and paces the room. Temperature is 37.6°C (99.7°), pulse is 110/min, respirations are 22/min, and blood pressure is 155/89 mm Hg. Physical examination discloses no other abnormalities. On mental status examination, he is alert and fully oriented. Serum thyroid-stimulating hormone concentration and results of a complete blood count and basic metabolic p

Educational Objective: Panic attacks are characterized by acute fear or anxiety that peaks within minutes and is associated with symptoms of sympathetic hyperactivity, such as tachycardia, heart palpitations, sweating, and trembling along with shortness of breath, chest pain, dizziness, gastrointestinal distress, and paresthesias. Patients with panic disorder experience recurrent panic attacks that are unexpected and associated with worry about future panic attacks or avoidance of panic attack triggers. Treatment typically includes psychotherapy, long-term selective serotonin reuptake inhibitors, and short-term benzodiazepines (eg, lorazepam).

Six hours after undergoing uncomplicated carotid endarterectomy, a 77-year-old man with hypertension reports left shoulder pain and difficulty breathing. He was admitted to the hospital 1 year ago for congestive heart failure. His temperature is 37"C (98.6"F), pulse is 90/min and irregular, respirations are 18/min, and blood pressure is 100/70 mm Hg. Pulse oximetry on 2 Umin of oxygen by nasal cannula shows an oxygen saturation of 92%. The surgical site is clean, dry, and intact. Crackles are heard at the left lung base. Heart sounds are normal. An ECG is shown. Which of the following is the most likely diagnosis?

Educational Objective: Patients with acute coronary syndrome (ACS) classically present with substernal chest pressure that may radiate to the neck, jaw, or left upper extremity, with associated dyspnea, nausea, and diaphoresis. ECG may show ST elevation, ST depression, T wave inversion, or may be unremarkable. Management of ACS includes administration of anticoagulation, antiplatelet agents, pain medications, and revascularization.

A 68-year-old woman comes to the office because of a 4-day history of progressive shortness of breath. She has chronic obstructive pulmonary disease, type 2 diabetes mellitus, hypertension, hyperlipidemia, and osteoarthritis. Her medications are metformin, losartan, lovastatin, and acetaminophen. She also uses continuous home oxygen therapy. Her temperature is 37°C (98.6°F), pulse is 70/min, respirations are 36/min, and blood pressure is 100/84 mm Hg. Pulseoximetry on room air shows an oxygen saturation of 82%. On pulmonary examination, diffuse crackles are heard bilaterally. On cardiac examination, an S3 gallop is heard. There is 4+ pitting edema of the lower extremities. Which of the following is most likely to confirm the diagnosis?

Educational Objective: Patients with heart failure classically present with dyspnea, orthopnea, lower extremity edema, and jugular venous distension. Physical examination may disclose pulmonary crackles and an S3 or S4 heart sound. Heart failure is diagnosed with echocardiography.

An 8-year-old girl with myelomeningocele at L4 is brought to the physician by her mother prior to transitioning from a special needs school to a public school. The patient uses a wheelchair. She is trained in self-catheterization. Her only medications are prophylactic antibiotics to prevent urinary tract infections. Muscle strength is 1/5 on hip flexion and adduction bilaterally. Her mother is concerned about how best to maintain her daughter's health in the new school. She notes that her daughter had a physical therapist and an occupational therapist in the classroom in the special needs school. Which of the following is the most appropriate recommendation?Train the patient to habitually change body position to alter areas of pressure

Educational Objective: Patients with limited mobility are at risk for pressure injury or ulceration. In general, pressure injuries occur over bony prominences. Clinical presentation may include nonblanchable erythema, warmth, and acute induration and deep ulceration in chronic, severe injuries. Frequent positional changes help prevent the development of a pressure injury. Once pressure injury has developed, strategies to offload pressure are used in addition to pain control, wound care, treatment of secondary infection, and optimizing nutrition.

Comprehensive Clinical Science Self-Assessment A 27-year-old woman is brought to the emergency department by her sister because of a 3-month history of strange behavior. The sister says the patient intermittently mumbles to herself and has refused to leave the apartment they share. The sister has not seen her eating during this time; yesterday, the patient disposed of all the food in the refrigerator because she insisted it was not safe to eat. She has no history of serious medical or psychiatric illness and takes nomedications. She does not drink alcohol or use illicit drugs. She appears distracted. She is 165 cm (5 ft 5 in) tall and weighs 51 kg (112 lb); BMI is 19 kg/m2. Physical examination shows no abnormalities. On mental status examination, she describes her mood as "OK." She has a flat affect. Her thought process is well organized and goal directed; there is no loosening of associations. She refuses to answer when asked if she has had auditory hallucinations. Which of thefollowing is the most likely diagnosis?

Educational Objective: Patients with schizophrenia have a history of at least two of the following five symptoms: delusions, hallucinations, disorganized speech, disorganized behavior, or negative symptoms (eg, flat affect, apathy, alogia). Mental status examination commonly shows evidence that the patient is experiencing hallucinations and has functional deficits, such as social withdrawal and poor hygiene. Treatment requires antipsychotic medications.

A 57-year-old man comes to the physician because of severe right shoulder pain since having a generalized tonic-clonic seizure 3 days ago. He first noted the pain in the emergency department, where he was brought after the seizure. He reports no other history of shoulder pain or injury. He has a 40-year history of a seizure disorder treated with phenytoin; his only other medication is acetaminophen for shoulder pain. On examination, passive and active range of motion of the right shoulder elicits pain. External rotation of the right shoulder is limited to 10 degrees. An AP x-ray of the shoulder obtained in the emergency department 3 days ago showed no abnormalities. Which of the following is the most appropriate next step in management?B) Lateral x-ray of the right shoulder

Educational Objective: Posterior dislocation of the shoulder can be a complication of a seizure. In cases of posterior shoulder dislocation, physical examination may disclose a prominent coracoid process with an anterior flattening of the shoulder. X- rays should include a lateral view, as an anteroposterior x-ray may miss up to 50% of posterior shoulder dislocations. Treatment includes closed reduction of the shoulder joint. In cases of recurrent dislocation and joint laxity, operative management may be indicated.

A 27-year-old woman comes to the physician for her first prenatal visit after a home pregnancy test was positive 1 week ago. Her last menstrual period was 9 weeks ago. She has a 9-year history of poorly controlled type 1 diabetes mellitus treated with insulin. Vital signs are within normal limits. Examination shows a uterus consistent in size with a 9-week gestation. Which of the following is the most appropriate test to assess the risk for fetal malformation in this patient?

Educational Objective: Preexisting diabetes mellitus in a pregnant patient is associated with both fetal and maternal risks, including macrosomia, neonatal hypoglycemia, severe birth defects, neurocognitive defects, preeclampsia, and spontaneous abortion. Measurement of hemoglobin A1c can be used as a marker of glycemic control. This measurement can also be used to assess a patient's risk for fetal malformations, as early exposure to marked maternal hyperglycemia greatly increases the risk for birth defects and spontaneous abortion.

A 12-year-old girl is brought to the physician by her mother because of a 1-month history of a lump in her right breast. The lump is not painful, and she has not had nipple discharge. She has no history of serious illness and takes no medications. She is at the 25th percentile for height and 50th percentile for weight and BMI. Examination shows no axillary lymphadenopathy. There is a 1 x 1-cm, smooth, rubbery, mobile mass beneath the areola in the right breast. Examination of the left breast shows no abnormalities. There are no skin changes or nipple discharge. Breast development is sexual maturity rating (SMR) stage 2 on the right and SMR stage 1 on the left. Pubic hair development is SMR stage 2. Which of the following is the most appropriate next step in management?Follow-up examination in 6 months

Educational Objective: Puberty is a normal part of adolescent development. In females, puberty usually begins between ages 8 to 12 years, with an average onset around age 9 years. The sexual maturity ratings (SMR) range from 1 to 5, marking the stages from prepuberty to full adult development. The finding of a smooth, rubbery, mobile mass beneath the areola is likely the breast bud, which is characteristic of SMR stage 2.

A 3402-g (7-lb 8-oz) male newborn has severe respiratory distress immediately after delivery. He was born at term following an uncomplicated pregnancy and delivery. He is gasping for air. The trachea is deviated to the right. Breath sounds are markedly decreased over the left hemithorax compared with the right hemithorax. Heart sounds are shifted to the right. The abdomen is markedly scaphoid. This patient is at greatest risk for death from which of the following? Pulmonary hypoplasia

Educational Objective: Pulmonary hypoplasia occurs as a sequela of congenital diaphragmatic hernia and results in serious and potentially life-threatening consequences to pulmonary and cardiac function. Pulmonary hypoplasia is caused by compression of the lungs by herniated abdominal organs with secondary changes in bronchial and vascular development

One week after undergoing splenectomy for injuries sustained in a motorcycle collision, a 19-year-old man has a platelet count of 1,250,000/mm3. Examination shows normal healing wounds. Which of the following is the most appropriate measure to prevent thrombotic events in this patient? aspirin

Educational Objective: Reactive thrombocytosis occurs commonly after splenectomy, and platelet counts typically peak in the first 1 to 3 weeks after surgery. Extreme thrombocytosis may lead to thrombotic events due to increased platelet aggregation, and this can be prevented by taking an antiplatelet agent.

Five days after undergoing abdominal hysterectomy for leiomyomata uteri, a 57-year-old woman is evaluated because of abscess formation and fascial dehiscence at the incision site. She is 165 cm (5 ft 5 in) tall and weighs 73 kg (162 lb); BMI is 27 kg/m 2. She received perioperative prophylaxis with an appropriate antibiotic 90 minutes after the surgical incision was made. Hospital recommendations specify that patients should receive antibiotic prophylaxis within 1 hour before the surgical incision is made. After admission to the hospital, patients are transferred to the preoperative holding area 30 to 90 minutes before their operation and then transferred to the operating room for induction of anesthesia. A patient's preoperative antibiotic prophylaxis may be administered by a nurse on admission or in the preoperative holding area or by the anesthesiologist during the induction of anesthesia. Which of the following is the most likely root cause of this error? A) Lack of standardized delivery and verification of delivery of antibiotic

Educational Objective: Root cause analysis (RCA) involves determining the core issue that led to an adverse event. Rather than presuming the cause of an adverse event, RCA involves a multidisciplinary team defining and analyzing the problem and designing a set of corrective actions based on the analysis.

23-year-old woman comes to student health services because of increasing anxiety about being called on in class for the past 6 weeks. Yesterday, she was so worried about being called on that she was shaking and spilled her coffee. Today, she was so frightened that she was unable to attend class. She says that she has always found it difficult to be the center of attention and has always avoided situations in which she would have to perform or speak in public. Physical examination shows no abnormalities. On mental status examination, she is cooperative and well dressed. She is anxious and tearful. Her thought process is organized. There is no evidence of suicidal ideation. Which of the following is the most appropriate next step in management?

Educational Objective: Social anxiety disorder refers to excessive fear of scrutiny or embarrassment in social and/or performance situations. Cognitive behavioral therapy and selective serotonin reuptake inhibitors are first-line treatments for social anxiety disorder. As-needed medications, such as propranolol, are commonly used to treat patients with social anxiety specific to performance situations.

17. A 37-year-old woman comes to the emergency department 2 hours after cutting her hand while working in the garden. She received a tetanus vaccine 3 months ago. Examination shows a clean wound. After the wound is treated, the patient insists on receiving another tetanus shot. The physician explains that the previous vaccine adequately protects her, but the patient insists that it be repeated. Which of the following is the most appropriate next step?Refuse to administer another vaccine and repeat the explanation

Educational Objective: Tetanus toxoid vaccine is not indicated in previously vaccinated patients with clean, minor wounds if their last vaccination was within 5 years. Patients requesting nonindicated or unnecessary medical care is a common ethical challenge that most physicians will face. The physician must balance between the ethical principles of autonomy (the patient should be allowed to make decisions regarding their own health care) and nonmaleficence (the physician should not take actions that will harm the patient). Physicians are not obligated to provide medical services that are not indicated, not necessary, or are potentially harmful.

A 47-year-old man is admitted to the hospital for repair of a recurrent right inguinal hernia. One year ago, he underwent bilateral inguinal hernia repair. He has hypertension well controlled with atenolol. Cardiopulmonary examination shows no abnormalities. There are well-healed surgical scars over the inguinal area bilaterally. The testes are descended, and a mass is palpated in the right groin on Valsalva maneuver. During the operation, the surgeon operates on the leftgroin. Which of the following is the most effective process to prevent this type of error in the future?Preoperative marking of the operative site by the surgeon with the patient's assistance

Educational Objective: The Joint Commission Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery was developed to reduce surgical errors and improve surgical reliability. Preprocedure actions include preoperative verification of the patient's identity, the procedure to be performed, and the surgical site. The surgical site should be marked by the surgeon who will perform the procedure and with the patient's assistance whenever possible, and thesurgical mark should be both unambiguous and positioned such that it will be visible after the surgical drape is placed.

A randomized clinical trial is planned to determine whether a new form of chemotherapy increases the survival time for patients with pancreatic cancer. The investigators intend to randomize 300 patients aged 40 to 70 years into two groups. One group will receive the new chemotherapy and the other group will receive standard therapy. Patients will be observed for up to 5 years. Interim analyses will be conducted on an annual basis, and the trial will be terminated ifsufficient evidence of efficacy is noted at any of the interim analyses. This interim analysis plan will most likely lead to which of the following?

Educational Objective: The likelihood of erroneously rejecting the null hypothesis (ie, concluding that the alternative hypothesis is true) is called a type I error. The acceptable rate of a type I error is a percentage called the a level and is set by the investigators. Interim analyses can sometimes be desirable for several reasons, such as efficiency, cost savings associated with longer clinical trials, and minimizing patient exposure to experimental treatments. However, it is important to consider that the a level describes the chance of type I error each time data analysis is performed. Therefore, repeated interim analyses inherently increase the chance of type I error.

A47-year-old man comes to the physician for a routine health maintenance examination. He reports no health problems. He has no history of serious illness and takes no medications. He does not smoke or drink alcohol. He has a sedentary lifestyle. There is no family history of coronary artery disease. He is 178 cm (5 ft 10 in) tall and weighs 79 kg (175 lb); BMI is 25 kg/m 2. His temperature is 36.5°C (97.?°F), pulse is 76/min, respirations are 10/min, and blood pressure is 120/70 mm Hg. Examination shows no abnormalities. Serum lipid studies show:

Educational Objective: The risk for cardiovascular disease can be decreased by lifestyle modifications and treatment of risk factors, such as obesity, tobacco use, diabetes mellitus, hypertension, and hyperlipidemia. While medical management of hyperlipidemia can decrease the risk for coronary artery disease, it can also cause adverse effects. Thus, the decision to start a statin should be based on consideration of an individual's risks and benefits. Those with an LDL-cholesterol concentration greater than 190 mg/dl or those with a 10-year cardiovascular risk greater than 10% should be prescribed a statin, while those with a less than 5% risk should undergo routine screening and follow-up.

A 22-year-old white woman, gravida 3, para 1, aborta 1, at 28 weeks' gestation comes to the office because of an itchy rash on her vulva that she first noticed yesterday. Two days ago at a routine prenatal visit, the patient reported a 2-day history of vaginal discharge. Wet mount preparation of the vaginal discharge disclosed trichomoniasis. Oral metronidazole was prescribed, which the patient began taking yesterday. Medical history is otherwise unremarkable. She has been taking prenatal vitamins. She is employed as an aide in a veterinary office. Vital signs are temperature 37.6"C (99.7°F), pulse 60/min, respirations 15/min, and blood pressure 120/76 mm Hg. Physical examination discloses the vulvar findings as shown in the photograph. Fundal height is consistent with a 28-week gestation. In addition to prescribing treatment for the itching, which of the following is the most appropriate recommendation?A ) She should avoid sharing towels and linens with household contacts

Educational Objective: Tinea cruris is associated with superficial dermatophyte infection, most commonly Trichophyton rubrum. Clinical examination will show annular or semiannular, pink plaques with central clearing. Diagnosis of tinea cruris may be clinical. However, skin scrapings with potassium hydroxide preparation show branching septate hyphae. Tinea cruris may be treated with topical azole antifungal agents, including ketoconazole. Superficial tinea infections are contagious, so it is recommended close contacts avoid sharing clothing, towels, or linens with unaffectedindividuals.

A 57-year-old man comes to the physician for a follow-up examination. One week ago, a fasting glucose test showed a serum glucose concentration of 128 mg/dl. He has no history of serious illness and takes no medications. He has no known allergies. He appears comfortable and is not in distress. He is 173 cm (5 ft 8 in) tall and weighs 111 kg (245 lb); BMI is 37 kg/m 2. His pulse is 82/min, and blood pressure is 130/84 mm Hg. Cardiopulmonary examination shows no abnormalities. Distal pulses are normal. Neurologic examination shows no focal findings. Laboratory studies are most likely to show which of the following?Increased serum C-peptide concentration

Educational Objective: Type 2 diabetes mellitus is characterized by insulin resistance, hyperglycemia, and progressive insulin deficiency. It tends to present later in life, usually after age 40 years. There is a general proinflammatory state with type 2 diabetes mellitus, and patients will have increased concentrations of acute phase reactants, such as interleukin-6 or C-reactive protein. Treatment includes lifestyle changes, oralantidiabetic agents, and insulin when needed.

A 24-year-old man with acute lymphoblastic leukemia is brought to the physician because of a tingling sensation in his hands and feet during the past 5 days. He also has nausea and vomiting. Three weeks ago, he completed a 2-week course of induction chemotherapy with vincristine, L-asparaginase, dexamethasone, cyclophosphamide, and cytarabine. On examination, cranial nerves are intact. Muscle strength is 5/5. Deep tendon reflexes are decreased bilaterally. Sensation to pinprick is decreased over the hands and feet. Which of the following is the most likely cause of this patient's current symptoms?Vincristine

Educational Objective: Vincristine inhibits microtubule formation, leading to the arrest of tumor cell division. It also disrupts microtubules involved in axonal transport, especially in sensory small fibers. Consequently, patients taking vincristine commonly present with signs of peripheral neuropathy, such as paresthesia.

A previously healthy 1-year-old boy is brought to the emergency department because of difficulty breathing for 12 hours. Over the past 2 days, he has had a cough and clear nasal discharge. His temperature is 36.5°C (97.?°F), pulse is 180/min, respirations are 60/min, and blood pressure is 70/46 mm Hg. He appears extremely anxious and apprehensive. Examination shows cool, pale, and mottled extremities. Pulses are thready. Scattered wheezes and bilateral basilar crackles are heard on auscultation of the chest; there is a gallop with no murmur. The liver is tender and palpated 6 cm below the right costal margin.

Educational Objective: Viral myocarditis can present in children with fever and signs and symptoms characteristic of heart failure, including volume overload, chest pain, shortness of breath, pulmonary edema, and an S3 gallop on physical examination.

A 92-year-old woman is brought to the emergency department because of a 1-week history of generalized fatigue and weakness. She has been a resident in a skilled nursing care facility for 30 years and is nonambulatory. This morning, she became agitated when the medical staff carefully lifted her arms and legs to move her on the bed. She has intestinal malabsorption syndrome, pulmonary fibrosis, dementia, and global deconditioning. She receives chronic parenteral nutrition. She appears pale and is oriented to person but not to place or time. She can follow simple commands. Palpation of the upper extremities and thighs produces pain. She can flex and extend the elbows and wrists and dorsiflex and plantarflex the ankles and extend the toes bilaterally. Sensation is intact over the extremities. Skeletal survey shows pseudofractures of the femur and proximal ulna bilaterally. Which of the following serum concentrations is most likely to be increased in this patient?

Educational Objective: Vitamin D deficiency can be caused by intestinal malabsorption, malnutrition, insufficient dietary intake, and decreased sun exposure. Osteomalacia is an adult form of vitamin D deficiency characterized by loss of bone mineral density and abnormal osteoid mineralization. Patients with osteomalacia present with nonspecific symptoms including muscular weakness, myalgia, bone pain, and in later stages may have bone deformity, gait alteration, and falls, or may show signs of hypocalcemia. X-rays may show pseudofractures.

A 42-year-old primigravid woman at 26 weeks' gestation comes to the physician for a routine prenatal visit. She feels well, and her pregnancy has been uncomplicated. Prior to conception, she used an oral contraceptive and dranktwo cups of coffee daily. She plans to resume using an oral contraceptive and drinking coffee after delivery. She states that after delivery, she will be taking a 6-month maternity leave from work and plans to breast-feed exclusively during this time. Examination shows a uterus consistent in size with a 26-week gestation. The most appropriate recommendation for the infant during breast-feeding is supplementation with which of the following?

Educational Objective: While breast-feeding can meet the full nutritional needs of an infant for the first 6 months of life, vitamin D supplementation should be encouraged for exclusively breast-fed infants. Vitamin D supplementation is important because breast milk does not contain sufficient quantities of vitamin D, deficiency of which can lead to childhood rickets. After age 6 months, complementary foods are introduced to a breast milk or formula-based diet, which provide further vitamins, energy, and iron supplementation.

A32-year-oldwomanisbroughttotheemergencydepartmentbecauseofa1-hourhistoryofpalpitations,tremors,light-headedness,andsweating.Shehasnothadlossofconsciousness,chestpain,orshortnessofbreath.Shehashad similar episodes in the past, which were relieved by eating and with rest. Her only medication is lorazepam as needed for generalized anxiety disorder. There is no family history of similar episodes. Her temperature is 37°C (98.6°F), pulse is 124/min, respirations are 24/min, and blood pressure is 138/90 mm Hg. Physical and mental status examinations show no abnormalities. Serum studies show:

Measurement of serum C peptide and glucose concentrations are obtained when there are concerns for an insulinoma. lnsulinomas are a rare tumor of the pancreatic islet cells that inappropriately produce excess amounts of insulin and C peptide, resulting in hypoglycemia. Signs and symptoms of an insulinoma include confusion, difficulty concentrating, sweating, fatigue, weakness, and fainting as a result of hypoglycemia. Symptoms are often precipitated either by a period of fasting or by strenuous exercise. Acute management of hypoglycemia is paramount for these patients to avoid more serious complications, such as seizures or fainting. lnsulinomas are generally small and benign but have been found on occasion to grow larger and metastasize. Diagnosis can be made by measuring 72-hour fasting serum insulin and glucose concentrations, C peptide concentration, as well as CT scan, MRI, or ultrasonography to locate and characterize the tumor. Definitive treatment is surgical removal, though diazoxide can be used to decrease insulin production in the interim.

A 27-year-old woman comes to the physician for a routine examination. She recently immigrated to the USA from Haiti.she had big vaccine in childhood. She feels well and is asymptomatic. She has a 6-year history of type 2 diabetes mellitus. Her fingerstick blood glucose concentration is 168 mg/dl. A PPD skin test produces 12 mm of induration at 48 hours. An x-ray of the chest shows no abnormalities. Which of the following is the most appropriate next step in management? A ) Repeat PPD skin test in 6 months C) Begin isoniazid therapy

topic: LATENT TB Educational Objective: Latent tuberculosis infection is a clinical diagnosis based on a positive immune response to tuberculosis antigens and patient risk factors. the immune response may be disclosed using the PPD skin test or an interferon-gamma release assay. For patients with greater than 10 mm induration on PPD skin test or a positive serum interferon-gamma release assay and a negative chest x-ray, treatment for latent TB infection should be initiated if they fall into one of the following high-risk groups: 1. recent immigration from a high-prevalence country, 2. intravenous substance use, 3. resident or employee of a setting in which people are in close contact (eg, correctional facility, nursing care facility, homeless shelter, hospital), 4. presence of significant medical comorbidities, 5.or pediatric patients exposed to high-risk adults. TX: CDC guidelines now favor a shorter (3 to 4 months) rifamycin-based and isoniazid combination regimen over isoniazid monotherapy, but only isoniazid monotherapy is also a correct choice. rifampin regimen has lower hepatotoxicity rate.