Level 3

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Deep venous thromboses located in vessels at and above the knee are at higher risk for embolization to the pulmonary vasculature than those found below the popliteal vein.

true

? is irregular uterine bleeding that occurs in the absence of recognizable pelvic pathology, general medical disease, or pregnancy. It reflects a disruption in the normal cyclic pattern of ovulatory hormonal stimulation to the endometrial lining. The bleeding is unpredictable in many ways. It may be excessively heavy or light and may be prolonged, frequent, or random. About 1% to 2% of women with improperly managed anovulatory bleeding eventually may develop endometrial cancer. The American College of Obstetricians and Gynecologists recently issued updated guidelines for the treatment of abnormal uterine bleeding caused by ovulatory dysfunction. They include the following recommendations. Surgery should be considered only in patients in whom medical treatment has failed, cannot be tolerated, or is contraindicated. Endometrial ablation is not acceptable as a primary therapy, because the procedure can hamper the later use of other common methods for monitoring the endometrium. Regardless of patient age, progestin therapy with the levonorgestrel intrauterine device should be considered; contraceptives containing a combination of estrogen and progesterone also provide effective treatment. Low-dose combination hormonal contraceptive therapy (20-35 μg ethinyl estradiol) is the mainstay of treatment for adolescents up to age 18 years. Either low-dose combination hormonal contraceptive treatment or progestin therapy is generally effective in women aged 19 to 39 years; high-dose estrogen therapy may benefit patients with an extremely heavy menstrual flow or hemodynamic instability. Medical treatment for women aged 40 years or older can, prior to menopause, consist of cyclic progestin therapy, low-dose oral contraceptive pills, the levonorgestrel intrauterine device, or cyclic hormone therapy. If medical therapy fails, patients should undergo further testing (eg, imaging or hysteroscopy). An in-office endometrial biopsy is preferable to dilation and curettage (D&C) when examining a patient for endometrial hyperplasia or cancer. If medical therapy fails in a woman in whom childbearing is complete, hysterectomy without cervical preservation may be considered. Acute episodes of heavy bleeding suggest an environment of prolonged estrogenic exposure and buildup of the lining. Bleeding usually is controlled within the first 24 hours, as the overgrown endometrium becomes pseudodecidualized. If flow fails to abate in 24 hours, D&C should be performed in all patients over the age of 35 who are diagnosed with DUB to rule out endometrial cancer. Hemorrhagic uterine bleeding requires high-dose estrogen therapy. If bleeding is not controlled within 12 to 24 hours, a D&C is indicated. Beginning progestin therapy shortly after initiating estrogen therapy to prevent a subsequent bleeding episode from treatment with prolonged unopposed estrogen is wise. In an acute setting, acute profuse bleeding should be first treated with conjugated equine estrogen (CEE) therapy. High doses of CEE exert a vasospastic action on capillary bleeding by affecting the level of fibrinogen, factor IV, and factor X in blood, as well as platelet aggregation and capillary permeability. Estrogen also induces formation of progesterone receptors, making subsequent treatment with progestins more effective. Most DUB is secondary to anovulation. In these patients, endometrium continues to proliferate with asynchronous development. As blood supply is outgrown, irregular shedding occurs. Bleeding might be controlled acutely with high-dose estrogen for a short period of time. Several hours are required to induce mitotic activity, so most regimens require 48 hours of therapy before continued bleeding is ruled a treatment failure. Estrogen therapy only controls bleeding acutely and does not treat the underlying cause. Appropriate long-term therapy can be administered once the acute episode has passed.

Dysfunctional uterine bleeding (DUB)

Iatrogenic trauma is the most common cause of epistaxis in children.

true

Osteoarthritis and labral tears may be treated with intra-articular injections.

true

Oxygen is a mainstay of therapy for acute coronary syndrome.

true

T12-L1 supplies sympathetic innervation the lower ureters and the prostate (T12-L2).

true

In addition, the Cobb angle in this patient is greater than 50 degrees which is consistent with severe scoliosis and can be associated with cardiopulmonary compromise, a surgical consult for consideration for fusion should be considered as well.

true Bottom Line: An appropriate treatment plan for a 42-year-old patient with severe scoliosis with back pain and somatic dysfunction should include Osteopathic Manipulative Treatment, strengthening exercises, surgical evaluation, and analgesia.

Bottom Line: Patients diagnosed with HSV esophagitis should undergo treatment with oral acyclovir.

true has odynophagia and dysphagia

Bottom Line: Coronary angiography demonstrating transient coronary spasm is the diagnostic hallmark of Prinzmetal variant angina. Treatment should include nitrates and calcium channel blockers.

------- should be suspected in children who demonstrate growth retardation and learning impairment and may have been exposed to anticonvulsants such as phenytoin in utero.

Fetal hydantoin syndrome

Visual acuity exam is important in the evaluation of eye complaints, but it will not be useful in diagnosing the problem.

TRUE

Grover disease (transient acantholytic dermatosis) is a benign, self-limited dermatologic condition that appears suddenly as an itchy papular rash over the trunk and is common in elderly men.

True

Hydatidiform mole is a type of gestational trophoblastic disease that presents with vaginal bleeding, hyperemesis, and absence of fetus on the ultrasound. The treatment of choice is dilatation and curettage, and it is important to carefully monitor human chorionic gonadotropin levels, as continued high levels of the hormone can indicate malignancy, which commonly metastasizes to the ----

lung.

Five days after initial presentation of MI, the patient returns to the emergency department experiencing severe chest pain. Physical examination reveals a holosystolic, high-pitched blowing murmur, loudest at the apex. What is the most likely diagnosis?

papillary muscle rupture The most likely diagnosis is a ruptured papillary muscle leading to acute mitral regurgitation. The risk of suffering a free wall rupture, interventricular septal rupture, or papillary muscle rupture is greatest 5 to 10 days following a myocardial infarction (MI) because macrophages have degraded important structural components of the myocardium in an attempt to repair the damaged tissue. The papillary muscles in the left ventricle are supplied by the left anterior descending coronary artery (LAD). Occlusion of the LAD is the most common cause of an MI, putting the papillary muscles at risk for necrosis. Once macrophages degrade the myocardium within the papillary muscles, they become weaker and are prone to rupture. A ruptured papillary muscle in the left ventricle leads to dysfunction of the mitral valve and subsequent regurgitation of blood back into the left atrium. Mitral regurgitation presents as a holosystolic high-pitched blowing murmur, which is loudest at the apex.

Be familiar with one medication that commonly causes flushing: niacin. Aspirin may also cause a degree of flushing and erythema.

true

Bottom Line: Always suspect right ventricular damage when clinical symptoms of elevated JVD, hepatomegaly, and hypotension are made, along with ST-segment elevation in inferior/right-sided leads in the presence of inferior wall MIs.

true

Bottom Line: Common risk factors for PE include immobility, hypercoagulable state, hospitalization, prolonged immobility, old age, and hormonal therapy.

true

Clinical hallmarks of VHL disease include the development of retinal and central nervous system (CNS) hemangioblastomas (blood vessel tumors), pheochromocytomas, multiple cysts in the pancreas and kidneys, and an increased risk for malignant transformation of renal cysts into renal cell carcinoma.

true

Conservative management is indicated for uncomplicated black widow spider bites. Do not forget to include local wound care and tetanus prophylaxis in these patients.

true

Dressler syndrome, or postmyocardial infarction syndrome, should be initially treated with NSAIDs.

true

Edrophonium is a short-acting acetylcholinesterase inhibitor and is used to help make the diagnosis of myasthenia gravis; this would not be useful in this patient.

true

Electromyography is performed to evaluate disorders of muscles and peripheral nerves. This study is not performed for vocal cord pathology.

true

Elevated reticulocytes are seen with red blood cell destruction (commonly hemolysis) or chronic blood loss. Splenomegaly may be seen in autoimmune hemolysis, but the hemoglobin/hematocrit is presumed normal and the only abnormality is thrombocytopenia, which suggests ITP more than autoimmune hemolysis.

true

Elevated white blood cells suggests leukemia which is also associated with thrombocytopenia and splenomegaly, however, leukemia would also present with other symptoms such as anemia, recurrent infections, weight loss and fatigue.

true

Epistaxis that is difficult to stop implies a posterior bleed and commonly involves the maxillary artery.

true

Fetal fibronectin (fFN) is used as a marker to assess the likelihood of preterm labor between 22-34 weeks of pregnancy.

true

Giardia is a protozoan that causes watery diarrhea. It is usually transmitted from contaminated water (the classic case is during a camping trip, where the patient drinks water from a stream).

true

Late decelerations are due to uteroplacental insufficiency that reduces oxygen delivery to the fetus. This is most often secondary to excessive uterine contraction. Other causes include spinal/epidural anesthesia, microvascular disease, placental abruption, severe maternal anemia, and maternal hypoxia.

true

Lateral strain occurs when the sphenoid deviates laterally in relation to the occiput. The cranium will feel like a parallelogram during palpation.

true

Pulmonary edema suggests transfusion-related acute lung injury. This presents with severe respiratory distress, and hypoxia and doesn't account for the rash.

true

Pulmonary function tests are of benefit in patients with severe scoliosis with Cobb angles greater than 50º.

true

Rashes are one of the most commonly tested pediatric topics on the COMLEX exams. It is essential that you understand the differences between their various presentations.

true

Remember that level 3 exams are much more clinically relevant than level 1 exams. Make sure you are familiar with the most common disorders such as BPH and DM. Suspect BPH in an older male with decreased urine output, nocturia, and weak urinary stream.

true

Rubella is characterized by generalized lymphadenopathy, an erythematous and tender maculopapular rash, and polyarthritis.

true

Terbutaline is a tocolytic. Because the patient likely has chorioamnionitis, it is not ok to stop labor. She needs to deliver the baby because of this suspected diagnosis.

true

The most likely diagnosis is focal nodular hyperplasia (FNH), which is a benign liver mass with no malignancy potential and a very low risk of complication, such as rupture or hemorrhage. FNH is best observed unless the mass grows large enough to cause pain, in which case surgical or interventional radiology procedures may be considered.

true

The parietal lobe is responsible for processing sensory input and body orientation and a lesion of this area can be seen in large strokes of the middle cerebral artery and often causes hemiparesis rather than tremor or dizziness.

true

The pooling of fluid in the vaginal vault is used in combination with nitrazine and fern testing to confirm the rupture of amniotic membranes.COMBANK Insight : Certain OB topics shown up on COMLEX exams over and over again. You need to be able to diagnose and treat PPROM and PROM.

true

The superior laryngeal nerve innervates the cricothyroid muscle. Damage to this nerve commonly results in choking as well as difficulty swallowing liquids. This nerve does not innervate the vocal cords.

true

The symptoms present in this patient are consistent with anaphylaxis. People with IgA deficiency are at increased risk for this reaction. IgA deficiency is generally a benign disorder that may not show any symptoms until a transfusion is done. The management for anaphylaxis is to stop the transfusion and give epinephrine.

true

This patient has an acute somatic dysfunction that is corroborated by her clinical presentation and manifested through corresponding tissue texture changes. Acute somatic dysfunctions often manifest with warmth and moisture upon palpation due to increased sympathetic stimulation.

true

This patient is demonstrating signs and symptoms consistent with necrotizing fasciitis. Necrotizing fasciitis is a progressive inflammatory infection that spreads rapidly and is located deep within the fascia, with secondary necrosis of the subcutaneous tissues. Subcutaneous air is a classic radiographic finding associated with this diagnosis and is caused by gas-forming organisms present within the fascia. Necrotizing fasciitis must be treated aggressively with emergent surgical irrigation and debridement. This is needed to combat the high morbidity and mortality that is seen when infection moves to deeper fascial planes.

true

This patient likely had infectious mononucleosis (IM)2 weeks prior and now has likely sustained a splenic rupture secondary to trauma while playing football. His illness 2 weeks ago is consistent with mononucleosis, and the fact that his doctor warned him about contact sports is a strong clue. He is tachycardic, suggesting at least 5-10% of blood volume loss, and the pain under the left shoulder is due to blood irritating the diaphragm. This patient has unstable vital signs and should have a bedside focused assessment with sonography in trauma (FAST) exam. If the FAST exam is positive for free fluid, he should be taken emergently to the OR.

true

This patient presents with acute cholangitis, a bacterial infection of the biliary tree, most commonly caused by obstruction but also associated with instrumentation, neoplasm, or stricture. Many patients can present with overwhelming sepsis, and if the biliary tree is obstructed, decompression is needed emergently. It is one of the few GI emergencies requiring immediate intervention. The most common organisms causing infection of the biliary tree are enterobacteriaceae, and as such, treatment should generally consist of broad spectrum gram negative antibiotics with additional anaerobic coverage. This can be achieved by the combination of a 3rd generation cephalosporin with metronidazole or with piperacillin/tazobactam alone. The most common cause of cholangitis is choledocholithiasis, which is likely in this patient. Overall, correct points are given for obtaining liver enzymes, a lactic acid, a chest x-ray, blood cultures, and an arterial blood gas (ABG) for the reasons outlined below. In patients presenting with sepsis or septic shock, CBC (for WBC count), basic metabolic panel (for creatinine and electrolytes), blood cultures, and appropriate imaging of the suspected source should be obtained. This patient has respiratory distress and hypoxia so a chest x-ray and ABG should be obtained to evaluate for causes of respiratory failure and acidosis and a serum lactate should be sent to guide resuscitation. She has a history of gallstones and is now presenting with jaundice so a liver profile should be ordered to evaluate for the pattern of liver injury present, cholestatic vs. hepatocellular. Coagulation studies will be needed as the concern for impacted gallstone is high, and the appropriate treatment would include endoscopic retrograde cholangiopancreatography (ERCP), possibly with sphincterotomy, and at the same time, acute liver failure can result in significantly elevated international normalized ratio due to decreased production of coagulation factors. Because obstruction can occur anywhere along the bile duct, there could be concomitant pancreatitis, so a lipase should be ordered. Ultrasound of the right upper quadrant could be considered as first-line imaging and generally is in stable patients; however, this patient is showing signs of severe sepsis.A right upper quadrant ultrasound will not provide enough information in a patient this ill to be of benefit for the following reasons: It cannot visualize distal stones. Very often it cannot visualize the pancreas due to overlying bowel gas so it cannot evaluate for pancreatic necrosis or need for surgical intervention secondary to obstruction and necrotizing pancreatitis. It cannot visualize tumors or abscess or the remainder of the abdomen well. An amylase may not be helpful if the patient is vomiting because it can be elevated due to salivary amylase (elevated after vomiting) or because of pancreatitis and is not as specific as a serum lipase. A CT of the abdomen/pelvis with contrast should be obtained once the patient is stabilized because it can visualize all of these structures with excellent detail. Lastly, this patient is presenting with acute altered mental status and signs of acute liver failure (jaundice, asterixis). One of the complications of this condition is cerebral edema. A CT of the head must be obtained to rule out this potentially lethal complication. If there is cerebral edema, it should be aggressively treated.

true

This presentation of a patient with severe flank pain with hematuria is most consistent with the patient passing a ureteral stone, while the tissue texture changes at T12-L1, which provides sympathetic information to the lower ureters, bladder, lower gastrointestinal tract and prostate in men, indicates that the urethrospasm and the stone are most likely in the distal ureter.

true

When the hCG is below threshold for identifying an intrauterine pregnancy in a stable patient, repeating the measurement in 48-hours is most appropriate.COMBANK Insight : OB topics are very common subjects tested on COMLEX exams because OB is considered a primary care specialty. Always remember to think like a primary care physician when taking COMLEX exams.

true

You would expect to see jaundice in a patient with intravascular hemolysis, however, the question stem does not give other symptoms or other lab work abnormalities aside from thrombocytopenia, to suggest hemolysis.

true

bicarbonate is the antidote used to alkalinize the urine in cases of aspirin (salicylate) toxicity and tricyclic antidepressant overdose.

true

high levels of magnesium (which inhibits parathyroid hormone).

true

von Hippel-Lindau syndrome is an autosomal dominant condition associated with renal cell carcinoma, pheochromocytomas, and hemangioblastomas.

true

Endoscopy is required to document healing of gastric ulcers, and to rule out gastric cancer. This usually is performed 6 to 8 weeks after the initial diagnosis of PUD. Documentation of H. pylori cure with a noninvasive test, such as the urea breath test or fecal antigen test, is appropriate in patients with complicated ulcers.

true A biopsy should be taken for all stomach ulcers that do not improve with standard peptic ulcer disease (PUD) therapy to rule out malignancy.

Gallstones (cholelithiasis) can be asymptomatic in many patients, however, they can also present with epigastric pain or right upper quadrant pain that radiates to the shoulder. Symptoms usually arise after a meal and spicy or fatty foods usually increase the severity of the pain due to increased stimulation of gallbladder contraction. An initial workup includes a CBC, electrolytes, liver function tests, amylase, lipase, and an ultrasound. All laboratory values may be within normal limits; however, an ultrasound will reveal gallstones.A CBC is helpful in the workup of a patient with abdominal pain to evaluate for increased WBC and signs of infection. A BMP or CMP would be helpful in the workup of a patient with abdominal pain to evaluate for electrolyte abnormalities due to third spacing and evaluate for elevation in hepatocellular enzyme levels or alkaline phosphatase due to biliary irritation. Liver function tests include aspartate aminotransferase, alanine aminotransferase, direct and indirect bilirubin, and alkaline phosphatase. These labs are usually within normal limits in the setting of asymptomatic cholelithiasis or regular biliary cholic, however, in acute cholecystitis or choledocholithiasis, an increase in AST, ALT, serum bilirubin, and alkaline phosphatase may be seen.An abdominal ultrasound is the test of choice in evaluating stable biliary pathology, such as this case, due to its ability to evaluate the bile ducts, gallbladder, and liver. In acute pancreatitis, serum amylase levels rise to greater than 3 times normal. The sensitivity of diagnosing acute pancreatitis with serum amylase levels is between 67-83% and specificity is between 85-98%. This would not be used exclusively to make the diagnosis but can be helpful. Amylase P, in particular, is more specific for pancreatic pathology. The serum levels rise within 6-12 hours of onset of acute pancreatitis. Lipase is the most specific laboratory test for pancreatitis and is often obtained without amylase levels. The 2 most common etiologies for pancreatitis are alcohol and gallstones and therefore patients presenting with right upper quadrant and epigastric pain should be evaluated for pancreatitis.

true A preoperative CBC is helpful to rule out anemia both to allow for optimization with iron as needed and as a cause of her chest pain. A type and screen should be ordered preoperatively in case the patient requires blood products during or after surgery. A preop basic metabolic panel would be helpful in evaluating any electrolyte abnormalities prior to surgery. A baseline EKG would not be recommended for patients undergoing low-risk surgery such as ambulatory surgery, breast surgery, endoscopic procedures, superficial procedures, and cataract surgery; however, EKG screening should be obtained when there are cardiac symptoms, such as in this patient with chest tightness.

The ------- is defined at the angle formed by the intersection of a line parallel to the superior endplate of the most superior vertebrae in a curve with a line parallel to the inferior endplate in the most inferior vertebrae in a curve in the coronal plan

Cobb angle Multiple risk factors correlate with progressive scoliosis. These largely relate to immaturity and earlier onset of diagnosis, severity of disease, and female gender. Of the choices listed only age >12 years predicts a decreased risk of progression to a Cobb angle of >40°. Eighty percent of cases of scoliosis are idiopathic; this can be further subdivided into infantile (<3 years of age), juvenile (3 to 10 years of age), adolescent (10 years to skeletal maturity), and adult. There is a possible genetic link because there is a higher propensity toward the disease in daughters of scoliotic mothers.

Bottom Line: Dysfunctions of the thoracic spine should be treated prior to any rib dysfunction.

true When addressing somatic dysfunction within the thoracic cage, treatment of the thoracic spine should occur before the treatment of ribs. Ribs are dependent on the costovertebral joints, which attach to the spine for normal movement, and often treatment of the thoracic spine will alleviate the rib dysfunction.

Bottom Line: Tearing chest pain with mid-scapular radiation in an elderly patient with known atherosclerosis and hypertension carries a high index of suspicion for aortic dissection.

true Diagnosis is made with computed tomography (CT) scan with contrast, which reveals the extent of the dissection. Transesophageal echocardiogram is highly sensitive and specific. Treatment depends on the type of dissection. Using the Stanford classification, type A dissection involves the ascending thoracic aorta, and emergent surgical repair is indicated. Type B dissections involve the descending aorta, distal to the left subclavian artery, and medical management is indicated without progressive dissection or vascular compromise. Medical treatment includes blood pressure control and risk factor modification. Complications include aortic rupture, aortic regurgitation, cardiac tamponade, and death.

Negative predictive value (NPV) is the probability that a patient with a negative test does not have a disease, calculated as:

(True Negative) / [(False Negative) + (True Negative)]

Specificity is the probability that a test will be negative in patients without a disease, calculated as

(True Negative) / [(False Positive) + (True Negative)].

Severe (late timing) toxicity of aspirin toxicity >750 mg/l will lead to

-Hallucinations -Stupor -Convulsions -Cerebral edema -Oliguria/renal failure -Cardiovascular failure -Coma Note- if aspirin is enteric coated, salicylate levels may not peak until more than 12 hours after ingestion. Chronic salicylate toxicity can also occur with prolonged exposure. GI side effects are less pronounced, but clinical course is otherwise similar.

C? corresponds to the triceps DTR, provides motor innervation to the elbow and finger extensors, and provides sensation to the third digit and palm.

C7 corresponds to the triceps DTR, provides motor innervation to the elbow and finger extensors, and provides sensation to the third digit and palm.

----- is primarily used for myopia and would not be the preferred surgical procedure in this scenario.

Keratotomy

Large-cell carcinoma is histologically described by the formation of large cells with prominent nucleoli, but without mucin production.

Large-cell carcinoma

-----may cause electrolyte disturbances, such as hypokalemia and hypernatremia. Hypokalemia can present with U waves on electrocardiogram.

Renal artery stenosis

---------Focal seizures can have retained or impaired awareness.

Seizures are now categorized as focal or generalized.

---- is used to treat aspirin toxicity. Aspirin toxicity is followed by measuring serum salicylate levels.

Sodium bicarbonate

: Developmental disorders may appear as a pediatric or psychology question. The most common developmental disorders that are tested on COMLEX exams include attention deficit/hyperactivity disorder, autism, Asperger, and oppositional defiant disorder.

TRUE

A ganglion cyst is an out-pouching of synovial tissue and presents as a painless mass. It can occur anywhere in the wrist and hand but is most common on the dorsal aspect of the wrist.

TRUE

Nodularity in the flexor digitorum superficialis tendon can cause ----------

a trigger finger,

Anovulatory cycles are common in adolescence and perimenopausal women. The most common reason is unopposed estrogen influence on the endometrium. The most common presentation is -----

abnormal vaginal bleeding.

Risk factors for --------include rupture of the membranes, drugs used to induce labor, older maternal age, uterine rupture, placenta previa, cesarean section delivery, eclampsia, and fetal distress during the pregnancy.

amniotic fluid embolism

Pyridoxine (otherwise known as vitamin ?) is generally given in conjunction with isoniazid to prevent peripheral neuropathy and other central nervous system side effects. It can also be used in acute toxicity and should be first-line therapy for central nervous system symptoms such as seizure. Pyridoxine is also the antidote for Gyromitra esculenta mushrooms and hydrazines found in rocket fuel.

Symptoms of ---- withdrawal are similar to those seen in withdrawal of BZDs, and ----- withdrawal can be life threatening and often includes: Anxiety Restlessness Insomnia Rhythmic intention tremor Dizziness Symptoms of withdrawal can progress to seizures, psychosis, hyperthermia, circulatory failure, and death.

barbiturate

Watson's test is performed by pushing the scaphoid anteroposterior with the wrist in radial or ulnar deviation. If the scaphoid subluxes or reduces, this suggests ------

carpal ligament injury.

Bethanechol is a ------. Anticholinergics are associated with delirium.

cholinergic agonist

Bottom Line: The most common cause of spontaneous small bowel fistulas is -----

crohn disease

Amyl nitrate converts hemoglobin into methemoglobin, which binds to ---- Other drugs to treat cyanide poisoning include sodium nitrate and thiosulfate, which are typically contained in cyanide antidote kits. Thiosulfate works more slowly than nitrates and should be used in conjunction.

cyanide.

Generally, the calcium channel blocker ------- is considered first line for rate control in hemodynamically stable atrial fibrillation. Avoidance of hemodynamic instability and tachycardia-mediated cardiomyopathy are the main reasons for which treatment of atrial fibrillation with rapid ventricular response is indicated. Many patients with his condition do not require hospitalization and can be treated safely as an outpatient.

diltiazem

Renal biopsy results in patients with Alport syndrome may show -------

glomerular basement membrane splitting.

testicular torsion

is a twisting of the spermatic cord that can lead to ischemia and possible testicular infarction. It typically presents with acute intense scrotal pain and is a surgical emergency.

The extensor pollicis brevis is innervated by the------

radial nerve.

Apple-green birefringence is associated with ----When the renal biopsy tissue is stained with Congo red stain and observed under polarized light, it leads to a classic apple-green color. Renal amyloidosis is common in patients with plasma cell dyscrasias, such as multiple myeloma.

renal amyloidosis.

The goal in ------ prevention is to treat early disease states in an asymptomatic individual and to prevent progression.

secondary prevention

The translocation in Burkitt lymphoma is ----c-myc. The c-myc oncogene on chromosome 8 is translated next to the heavy chain Ig gene on chromosome 14.

t(8;14) While classically described in neuroblastoma, n-myc is involved in a variety of cancers. The translocation in Burkitt lymphoma is t(8;14) n-myc. The n-myc oncogene on chromosome 8 is translated next to the heavy chain Ig gene on chromosome 14. This is very similar to the c-myc translocation.

The extensor carpi radialis brevis tendon is part of the second compartment and is responsible for -----

tendonitis (carpal bossing).

Lichen sclerosis et atrophicus is a chronic, painful, pruritic disease that most commonly affects the vulva of postmenopausal women. Lesions appear as shiny, atrophic patches and plaques. First-line treatment is a potent topical corticosteroid, such as clobetasol. If this is not effective,---------- may be used.

topical calcineurin inhibitors, such as tacrolimus, may be used.

1. Richter transformation This patient with treated CLL is now presenting with signs and symptoms highly concerning for Richter transformation. This is, most commonly, the sudden conversion of CLL to a diffuse large B-cell lymphoma. It generally presents with sudden onset night sweats, enlarging lymph nodes, and splenomegaly. It represents a highly aggressive disease with a poor prognosis. There are multiple chemotherapy regimens and targeted therapies, but none of them have clearly affected long-term outcomes. Allogeneic stem-cell transplantation may offer a chance for long-term survival, but has significant side effects and possible morbidity. Additionally, many patients will not qualify for stem-cell transplantation due to poor disease control, poor performance status or lack of donor. Overall the prognosis remains poor.Bottom Line: Patients with CLL may convert to an aggressive diffuse large B-cell lymphoma known as Richter transformation which carries a poor prognosis.

true

A fundoscopic exam should be done in a patient with elevated blood pressure and headache to evaluate for papilledema..

true

All of the signs and symptoms, in this case, are consistent with a diagnosis of infectious mononucleosis. The most common cause is an Epstein-Bar virus (EBV) infection, which is prevalent among college students. Patients with splenomegaly are at risk for splenic rupture and should avoid contact sports until the spleen resumes a normal size.

true

Allogeneic bone marrow transplant is a treatment used in diseases involving bone marrow such as aplastic anemia, certain lymphomas, and leukemia

true

Although this is a physical exam test for ACL injury, this is done with a supine patient with the hip flexed 30 degrees and abducted. The examiner then internally rotates and extends and flexes the patient's knees through a series of motions to asses anterior subluxation.

true

Alzheimer's is generally a slow, progressive dementia over the years and is recognized by the family long before the patient needs help with ADLs.

true

Bottom Line: Benzodiazepines work by modifying gamma-aminobutyric acid (GABA) receptors to increase conductance of this inhibitory channel.

true

Bottom Line: Carpal tunnel syndrome (CTS) may be caused by severe, long-term, untreated hypothyroidism. Although the association between hypothyroidism and CTS is not fully understood, hypothyroidism is known to cause fluid retention, resulting in swollen tissues that exert pressure on the median nerve.

true

Bottom Line: Cautious preservation of parathyroid tissue during a thyroidectomy is especially important in a patient with history of gastric bypass surgery since calcium is mainly absorbed in the duodenum and such patients may already have calcium deficiency

true

Capillary hemangiomas are benign hamartomatous tumors with no malignant potential.

true

Rotavirus causes watery diarrhea and dehydration in infants.

true

Sepsis caused by Gram-positive bacteria can result from an immunological response to cell-wall lipoteichoic acid.

true

Suboccipital release is an excellent indirect method of treating diagnosed somatic dysfunction to the occipitoatlantal (OA) region and freeing the vagus nerve. Parasympathetics to the lung cause constriction of bronchial smooth muscle and decreased goblet cell production, promoting the production of thin secretions.

true

The Nikolsky sign is positive when pressure applied to the base of a blister results in sloughing of the skin and is positive in conditions such as pemphigus vulgaris and toxic epidermal necrolysis.

true

The first-line treatment for panic disorder is a selective serotonin reuptake inhibitor. Benzodiazepines can be used in select patients in the short term.

true

Third-generation thyroid-stimulating hormone (TSH) assays are generally the most sensitive screening tool for primary hypothyroidism. If TSH levels are above the reference range, the next step is to measure free thyroxine (T4) or the free thyroxine index (FTI), which serves as a surrogate of the free hormone level.

true

Umbilical cord spam or compression results in variable decelerations. These are defined as abrupt decreases in fetal heart rate, with rapid return to baseline.

true

Weekly phlebotomy is the best initial therapy for acute, symptomatic hemochromatosis with signs of end-organ damage secondary to iron overload.

true

Clomipramine is a tricyclic antidepressant most effectively used for the treatment of obsessive-compulsive disorder and provides no assistance for smoking cessation.

true Bupropion is contraindicated in patients with a history of seizures. Common side effects of bupropion therapy include the following: insomnia, seizures, sweating, weight loss, and decreased appetite.

Bottom Line: Multiple sexual partners, early onset of intercourse, and prior history of sexually transmitted diseases are major risk factors for acquiring cervical cancer because of its strong association with HPV (strains 16 and 18) infections. Cervical cancer is the second most common malignancy in women worldwide, and it remains a leading cause of cancer-related death for women in developing countries. In the United States, cervical cancer is relatively uncommon.

true The most important information to obtain from this patient is her sexual history. Major risk factors include multiple sexual partners, early onset of intercourse, and prior history of sexually transmitted diseases. Recent studies have isolated human papillomavirus (HPV) DNA in greater than 90% of squamous intraepithelial lesions. HPV strains 16 and 18, in particular, have been linked with cervical cancer in young women.

Hip fractures generally represent fragility fractures commonly due to underlying osteoporosis. Treatment should be aimed at optimizing a patient's bone health for the prevention of additional fractures.

vitamin D, calcium and also get PTH level

---is the absolute avoidance of a painful reality. It is common in newly diagnosed patients with AIDS and cancer.

Denial

------- present with a scaphoid abdomen and respiratory distress requiring mechanical ventilation. The diagnosis is confirmed on X-ray when bowel contents are visualized in the thorax. As always, the airway should be secured prior to imaging in the case of respiratory distress.

Congenital diaphragmatic hernias

You are attending to a 34-year-old female who received multiple lacerations with significant bleeding from a motor vehicle accident. The bleeding has stopped but now she has an Hg of 7.3 (reference range: 12.0-16.0 g/dL) with symptoms of dizziness. While transfusing two units of packed red blood cells she develops a fever of 100.7 F (38.2 C). Close follow-up reveals no hemoglobinuria and culture of the blood product showed no growth. These reactions could have been prevented by: A. infusing blood over 12 hours B. infusing Cefazolin at same time as blood C. premedicating with diphenhydramine and acetaminophen D. using blood from 1st degree relatives only E. using blood that is leukoreduced

E. using blood that is leukoreduced

The -------- is a potential source of bias in meta-analyses and refers to confounding by group variables. For example, included studies may not report individual-level data, and so a researcher completing a meta-analysis will need to analyze the participants according to the group-level information presented in the paper. If the average characteristics of the group do not reflect the individual characteristics, bias can be introduced, but there is no way to predict in advance if this type of bias would sway the conclusions toward a type I rather than a type II error.

ecological fallacy

Bottom Line: Thyroid cancers are solid and cold ("Cold as ice!"). Remember the "P's" of ---- most Popular, Papillae, "Pupil" nuclei (Orphan Annie nuclei), Psammoma bodies, and Positive Prognosis.

papillary thyroid carcinoma:

A pinguecula is similar histologically to a pterygium. Both may be due to actinic damage to the conjunctiva with elastotic degeneration of the conjunctival stroma. The typical presentation is a raised yellowish nodule on either the temporal or nasal side of the cornea without extension onto the cornea and with less prominent vascularity. Treatment is similar to treatment for pterygia.

pinguecula

Anal fissures are a very common cause of rectal blood in a young child. They are strongly associated with straining and constipation. This can be secondary to a myriad of factors, but all result in mechanical strain and perianal tears. Fissure is easily identified on physical exam. This patient did not have any notable findings on physical exam, and the patient's mother denies issues with constipation.

true

Bottom Line: A patient with symptomatic severe aortic stenosis need valve replacement as the prognosis is very poor once symptoms begin. The decision on SAVR vs TAVR is complex but in general, the heart team should meet to inform the patient on the benefits and risk of each approach.

true

The uterine size is evaluated by measuring the distance from the pubic symphysis to the top of the fundus in centimeters. At 20 to 35 weeks, the measurement in centimeters corresponds to the number of weeks gestation. If there is a discrepancy of greater than 2 cm, an ultrasound should be performed to evaluate further to rule out intrauterine growth retardation or a multiple gestation pregnancy. Fetal heart tones can be heard with Doppler ultrasound typically at 10 to 12 weeks, however newer modalities allow them to be heard as early as 5 weeks. At 16 to 20 weeks, the most accurate method of estimating the fetal age is measuring the biparietal diameter with ultrasound.

true

Bottom Line: The rectus femoris originates at the anterior inferior iliac spine.

true

Bracing with the wrist in the neutral position and stretching exercises are the first-line treatment for carpal tunnel syndrome.

true

By 10 months, children should be able crawl, pull themselves up to stand, use an immature pincer grasp, and wave bye-bye.

true

Churg-Strauss syndrome is a systemic inflammatory disease characterized by asthma, eosinophilia, and involvement of various organ systems such as the upper and lower respiratory tract, the peripheral nervous system, the skin, the kidney, and the gastrointestinal tract.

true

Fomepizole is the best initial antidote for ethylene glycol or methanol poisoning. It is considered superior to the other antidote, ethanol infusion, since it is not intoxicating.

true

Paroxetine and venlafaxine are 2 antidepressants with the highest risk of developing discontinuation syndrome. When stopping these 2 medications, a slow taper over several weeks is recommended.

true

------- is the combination of erythema nodosum, bilateral hilar adenopathy (as shown in the exhibit), migratory polyarthralgias, and fever in a patient with sarcoidosis

Lofgren's syndrome

Cocaine

----would more likely cause euphoria, tachycardia, pupillary dilation, hypertension, and hallucinations.

Arsenic poisoning

------ can be caused by pesticides or contaminated ground water. It presents with severe headaches, abdominal pain, diarrhea, delirium, convulsions, and breath that smells like garlic. It can be treated with chelating agents such as succimer or dimercaprol.

Bottom Line: In patients with HELLP syndrome, vaginal delivery should be performed after -----weeks of gestation.

34 weeks of gestation.

----usually occurs 5 to 10 days following an MI and may lead to cardiac tamponade, which presents with muffled heart sounds, jugular venous distension, and pulsus paradoxus.

A free wall rupture

Zafirlukast and montelukast are examples of leukotriene receptor antagonists. used to treat?

ASTHMA Antagonizes leukotriene D4 and E4

inevitable abortion

An inevitable abortion occurs when the cervix has dilated during the first trimester of pregnancy without passage of the products of conception. Symptoms of cramping and bleeding may occur. Treatment is with dilatation and curettage.

------- is the best screening test for diagnosing acalculous cholecystitis and may show bile sludge, pericholecystic fluid, and thickened gallbladder walls.

An ultrasound

Although this is a physical exam test for ACL injury, this is done with a supine patient with hips flexed 45 degrees and knees flexed to 90 degrees. The examiner then draws the tibia forward anteriorly, with excess displacement suggesting ACL injury.

Anterior drawer test

----- is the antidote for cholinergic overdose (organophosphate, carbamate insecticide, or nerve agent poisoning). Atropine works by blocking the action of acetylcholine at parasympathetic sites in smooth muscle, secretory glands, and the CNS; it increases cardiac output, and dries secretions. When used for overdose, atropine acts as a competitive antagonist of acetylcholine at muscarinic receptors.

Atropine

------ is a cytotoxic medication that can be used as a treatment to induce immunosuppression for transplant patients and rheumatologic disease. The drug does not cause pulmonary side effects. It is most often associated with nausea, vomiting, and myelosuppression. It may rarely cause hepatotoxicity and pancreatitis and is associated with later development of certain kinds of cancer.

Azathioprine

----- is the most frequently found anaerobe in the colon.

Bacteroides fragilis

? is important to monitor and use to adjust fluids in patients where blood loss is the life-threatening problem.

Blood pressure

------ is decreased in Wilson disease, which is due to copper accumulation.

Ceruloplasmin

Children treated with methylphenidate may suffer from

Children treated with methylphenidate may suffer from decreased appetite and demonstrate tics, which may alarm parents.

Complete abortion

Complete abortion is the expulsion of all products of conception. Slight bleeding occurs. A closed cervical os with an empty uterus on ultrasound is seen. No treatment is needed, but follow-up is appropriate.

------ is a mild traumatic brain injury associated with temporary loss of brain function, without any structural changes on imaging.

Concussion

--------, is a setting in which a specific pressure is set, allowing the airways to remain open, and allowing spontaneous breaths by the patient. The patient can over-breath the ventilator but must receive the set amount of breaths that are set per minute and only receives pressure support. This is a common weaning setting used in the ICU.

Continuous positive airway pressure, or CPAP

may be treated with amyl nitrite and thiosulfate. Amyl nitrite is used first because it produces methemoglobin, which combines with the cyanide to form cyanide methemoglobin. Thiosulfate is then added, which converts the cyanide methemoglobin into thiocyanate, which can be excreted.

Cyanide poisoning

------is the least abundant of the 3 estrogenic hormones (estradiol, estriol, and estrone).

Estrone

-----is administered to patients in whom a benzodiazepine overdose is suspected. It works by competitively inhibiting the activity at the benzodiazepine receptor site on the GABA/benzodiazepine receptor complex

Flumazenil

----- is the antidote for beta-blocker toxicity.

Glucagon

Linear anti-GBM deposits are associated with ------which presents with renal and respiratory symptoms such as dyspnea and hemoptysis.

Goodpasture syndrome,

Bottom Line: The most common symptoms of digoxin toxicity are gastrointestinal distress, blurry vision, and arrhythmia. -----can enhance digoxin toxicity.

Hypokalemia The most common symptoms of digoxin toxicity are gastrointestinal distress, blurred vision, and arrhythmia. Heart block (as seen with the prolonged PR interval) is a common side effect of digoxin, which usually does not cause problems. Hypokalemia and renal failure can enhance digoxin toxicity. Treatment is with anti-digitalis fractionated antibodies, magnesium, and lidocaine for torsades.

IgA Nephropathy (also known as Berger's disease) is the most common type of nephropathy and presents within days of an infection. It does not affect C3 levels. It causes deposition of IgA in the glomerulus and is commonly affected with ?

Henoch-Schoenlein purpura.

are caused by fluid accumulation in the processus vaginalis, which is an embryologic remnant. It is usually asymptomatic and will transilluminate on physical exam. Treatment is usually observation, unless it persists beyond a year or is associated with a symptomatic hernia.

Hydroceles

------is a settling of blood in the anterior chamber, which may present as layering inferiorly to filling of the entire chamber.

Hyphema

In addition to supportive therapy with respiratory support, sedation, and elevation of the head of the bed, hypertonic saline is a good choice for acutely lowering ------

ICP.

-------- is a normal finding in early pregnancy. If fasting blood glucose was also elevated, then there would be concern for gestational diabetes.

Isolated glucosuria

Methamphetamines

Methamphetamines would most likely cause hypertension, pupillary dilation, fever, euphoria, and prolonged wakefulness.

Bottom Line: ------ presents with the classic symptoms of hypothermia, bradycardia, and altered mental status.

Myxedema coma In the setting of myxedema coma, the most important initial management steps in the stabilized patient, include the administration of levothyroxine and hydrocortisone.

Bottom Line: ----- (ie, trephination) is the treatment of choice for a painful subungual hematoma.

Nail drilling

------ is the agent of choice in opioid overdose. It works by antagonizing opioid receptors. Opioid overdose can have some similar signs and symptoms to tricyclic antidepressant overdose, such as urinary retention, hypotension, and decreased gastrointestinal motility. However, classic signs and symptoms of opioid overdose include respiratory depression, miosis, drowsiness, nausea, vomiting, and histamine release resulting in urticaria and bronchospasm.

Naloxone

Eponyms for the nodules are Bouchard nodes for PIP involvement and Heberden nodes for DIP nodules.

OA Asymmetric joint involvement is characteristic of primary osteoarthritis initially but like rheumatoid arthritis it can present in a symmetric pattern in later stages of the disease process.

-------- can occur in patients exposed to pesticides. It presents with salivation, lacrimation, urination, fecal incontinence, diaphoresis, blurry vision, hypotension, bradycardia, and muscle fasiculations. It can be treated with atropine.

Organophosphate poisoning

----, also known as preseptal cellulitis, is an inflammation and infection of the eyelid and portions of skin around the eye anterior to the orbital septum. It may be caused by breaks in the skin around the eye and subsequent spread to the eyelid, infection of the sinuses around the nose (sinusitis), or spread of an infection elsewhere through the blood. Extraocular movements should not be affected.

Periorbital cellulitis

Positive predictive value (PPV) is the probability that a patient with a positive test has a disease, calculated as:

Positive predictive value (PPV) is the probability that a patient with a positive test has a disease, calculated as: (True Positive) / [(True Positive) + (False Positive)].

Prevalence

Prevalence is the total number of existing cases of a disease divided by the total population in the area.

-------is used for atrial fibrillation with Wolff-Parkinson-White (WPW) syndrome, where AV nodal blocking agents like calcium channel blockers should be avoided. WPW is caused by a separate accessory conduction pathway between the atria and ventricles and returns a conduction impulse to the AV node. An ECG will show a delta wave and shortened PR interval.

Procainamide

Bottom Line: The most common organism associated with cholangitis is Escherichia coli.

true

-------- is one of the most common causes of secondary hypertension in this age group and should be suspected in younger patients who have elevated blood pressure.

Renal artery stenosis due to fibromuscular dysplasia, or renovascular hypertension, is one of the most common cause of secondary hypertension in patients aged 19-39 years old. The best test to order when the diagnosis of renal artery stenosis is suspected is duplex Doppler ultrasonography of the kidneys.

Rhabdomyolyis

Rhabdomyolyis is the most potentially lethal and dangerous complication associated with the use of physical restraints. Rhabdomyolysis is a very dangerous and potentially lethal complication of physical restraint use because of its sequelae, which include hyperkalemia and acute renal failure. This occurs secondary to the patient's continuous struggle against the restraints and eventual muscle breakdown.

----- require 3 important diagnostic tests: seated flexion test, depth of the sulci, and depth of the inferior lateral angles.

Sacral dysfunctions A positive seated flexion on the right indicates a sacral somatic dysfunction affecting the right side. An anterior sacral base on the right indicates a flexion dysfunction, and a concurrent posterior inferior lateral angle on the right indicates a unilateral dysfunction on the right side. Therefore, this patient's structural exam is consistent with a right unilateral sacral flexion, which is likely the cause of her low back pain.

Type III hypersensitivity reactions are antigen-antibody complex reactions that activate complement and release of C5a, a potent neutrophil chemotactic factor. -------- is an example of a type III hypersensitivity reaction.

Serum sickness

C. discontinue azithromycin This patient has completed longer than the standard treatment for community-acquired pneumonia. Despite improvement of her initial symptoms of illness, including fever and productive cough, she is experiencing increased shortness of breath and continued ptosis, suggesting worsening of her myasthenia gravis (MG).Although the most common cause of exacerbation of MG is infection, an important distinction is the role of medications exacerbating disease as well. Among these are innumerable antibiotics including macrolides, fluoroquinolones, and penicillins. Nonantibiotic medications frequently implicated include beta-blockers, calcium channel blockers, gabapentin, and importantly, corticosteroids. The latter is of significant importance because although corticosteroids are often a part of the treatment for MG flares, paradoxical worsening may occur in half of all patients with MG, and myasthenia crisis occurs in up to 18% of these patients. Therefore, among patients with MG, corticosteroid administration should always be administered in the hospital setting. Increasing azithromycin would further exacerbate the diplopia and blurry vision. It may enhance respiratory weakness and, with the patient's underlying severe pneumonia, could result in respiratory failure. Additionally, when considering treatment failure of an antibiotic with adequate dosing and duration, increasing the dose of the same antibiotic is unlikely to be of further benefit. Answer A: The addition of a fluoroquinolone would further worsen this patient's symptoms. Although treatment failure may be considered due to her adequate course of 5 days, improvement of some of her initial infectious symptoms, clear x-ray, and primary symptom of poor effort secondary to fatigue point toward worsening of her MG.Answer B: Although the cephalosporins have not been reported to exacerbate symptoms of MG, the addition of a fluoroquinolone should be avoided, as discussed above.

She has completed 7/10 days of the azithromycin prescribed by the emergency department. She states that although her fever and cough have improved, the dyspnea has worsened despite continued use of her prescribed regimen. Physical exam reveals clear lungs with diminished effort and notable ptosis. Two-view chest x-ray performed in office appears clear. What is the most appropriate next step? A. add ciprofloxacin to existing regimen B. administer ciprofloxacin and ceftriaxone C. discontinue azithromycin D. increase the dose of azithromycin E. oral prednisone and follow up in 1 week

----------are the initial treatment choices for patients suspected of having anal fissures.

Sitz bath and stool softeners Sphincterotomy is the last resort for anal fissures when medical therapy doesn't work. The second-line therapy in conservative management is to use a nitroglycerin ointment or calcium channel blocker ointment. Anoscopy should be done after the acute symptoms have subsided to rule out any other pathology that could be causing blood in the anus. If you try to perform an anoscopy in the office, the patient will suffer too much pain and there is the potential that the tear could be made worse by your exam.

------ (SCFE) is most common in the adolescent period. Treatment consists of surgical pinning and weight-bearing restrictions. Prophylactic pinning of the normal contralateral side is also performed in cases of hypothyroidism.

Slipped capital femoral epiphysis

This checks for a cervical radiculopathy by extending and rotating the head to the affected side and applying downward pressure.

Spurling test

Classic mammography findings consistent with breast cancer include small clusters of calcifications and spiculated masses with irregular asymmetrical borders. what is the next step in diagnosis?

Stereotactic core biopsy is the next best step.

This innervates the subscapularis and teres major

Subscapular nerve

--------- is also a common deformity associated with rheumatoid arthritis. Synovitis causes volar plate laxity, leading to hyperextension of the PIP joint. At the DIP joint, there is elongation or rupture of the extensor tendon attachment from the base of the distal phalanx, leading to DIP joint flexion.

Swan neck deformity

usually presents with painless enlargement of the testes with or without accessory palpable masses. Treatment consists of radical orchiectomy.

Testicular cancer

The Centers for Medicare and Medicaid Services (CMS) -----

The Centers for Medicare and Medicaid Services (CMS) is a federal agency that administers the Medicare program (social health insurance for those >65 years old) and works in partnership with state governments to administer Medicaid (for those with low income).

----- measurements are not useful for corneal abrasions. Tonometry is useful for the diagnosis of acute closed-angle glaucoma and indicates an increase in intraocular pressure.

Tonometry

------ is a monoclonal antibody against HER-2 (erb-B2) used in the treatment of HER-2 positive breast cancers. A major side effect of -------- is cardiotoxicity.

Trastuzumab

Primary adrenal insufficiency presents with low cortisol, high ACTH, low aldosterone, high renin, hyperkalemia, hyponatremia, hypoglycemia and hypotension. ------ is a possible cause in the homeless population.

Tuberculosis

occurs less often than the other answer choices. Injury to the vagina wall is seen more often in the post-menopausal population.

Vaginal wall injury

------- is a potential life-threatening complication of central line placement and typically presents with sudden-onset dyspnea with the presence of a "mill-wheel" murmur on physical examination.

Venous air embolism

------ is used to treat warfarin toxicity with no active bleeding (eg, melena). Warfarin toxicity is followed by measuring PT/INR levels.

Vitamin K

All patients who have suffered a penetrating cat bite should be treated with prophylactic antibiotics. Current recommendations include -----

amoxicillin/clavulanate or a second-generation cephalosporin.

Bottom Line: Patients with Down syndrome are at an increased risk for developing Alzheimer's disease due to the presence of trisomy 21 and its association with abnormal production of --------

amyloid precursor protein.

Bottom Line: Iron deficiency anemia is a microcytic, hypochromic anemia, which is a common diagnosis in vegetarians who present with fatigue. Transferrin would be ----- secondary to decrease in iron binding.

elevated

atorvastatin 40 to 80 mg or rosuvastatin 20 to 40 mg. are both

high intensity statins

Bottom Line: Tinnitus and metallic taste are early symptoms of-------toxicity.

lidocaine

Ectopic pregnancy is predisposed by-----

salpingitis.

Hirsutism is a common adverse reaction of minoxidil.

true

Lymphoid tissue is the most radiosensitive tissue in the body.

true

Cavernous hemangiomas are the most common benign tumors of the liver.

true

The patient above is presenting in septic shock presumed secondary to endocarditis. Findings suggestive of endocarditis in this patient include the Janeway lesion seen on the hand (painless erythematous macule or papule on the hands or fingers), track marks suggestive of IV drug use, and a heart murmur suggestive of a valvular vegetation. The patient needs immediate fluid resuscitation before any of the other options. Sepsis is an inflammatory cascade which, if unopposed, can result in tissue hypoxia and organ failure. Sepsis is important to recognize as it carries a high rate of mortality.The definition of sepsis is based on expert opinion, and currently accepted definitions are formed by consensus of the Society of Critical Care Medicine (SCCM) and the European Society of Intensive Care Medicine (ESICM); however, these are not diagnostic of sepsis. According to these organizations, sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection (the Sepsis-3 definition). However, many health care organizations still use systemic inflammatory response syndrome (SIRS) to identify sepsis, as Centers for Medicare and Medicaid Services (CMS) still supports this definition, where 2 of 4 SIRS criteria (see below), plus possible source of infection, are diagnostic of sepsis.Current guidelines recommend the administration of IV crystalloids, including normal saline in a volume of 30ml/kg started within one hour of presentation and completed in the first three hours of presentation. In addition, IV antibiotics should be given in the first hour of presentation. Septic shock is defined as persistent hypotension despite aggressive fluid resuscitation. If hypotension is not immediately addressed, prolonged organ hypoperfusion can lead to severe multiple organ dysfunction and death. SIRS is a natural physiologic response to any kind of inflammatory process, and the criteria can be met without any signs of infection. Pain alone can cause SIRS with elevated heart rate and respiratory rate; however, generally the pain would not cause a fever. Severe pain and injury, however, have been known to cause a reactive leukocytosis, such as seen with trauma victims. CMS definition criteria: Systemic inflammatory response syndrome (SIRS) requires 2 of the following 4:1. elevated HR > 90 bpm2. leukocytosis (WBC > 12,000 cells/mm3), leukopenia (WBC < 4,000 cells/mm3), or > 10% immature forms (bands)3. temperature > 38o C or < 36o C4. respiratory rate > 20/min or PCO2 < 32 mmHgSepsis: 2 out of 4 SIRS criteria + possible source of infection Septic shock: Despite adequate fluid resuscitation, patient meets sepsis criteria, plus:1. Lactic acid > 2 mmol/L (> 18mg/dL), or2. Patient requires vasopressors to maintain mean arterial pressure (MAP) < 65 mmHgMultiple organ dysfunction syndrome (MODS):Primary: organ dysfunction directly due to insult (rhabdomyolysis causing renal failure)Secondary: organ dysfunction indirectly due to insult, and more likely due to host response (examples: elevated liver enzymes or bilirubin indicating liver failure, decreased GCS indicating hypoperfusion of the brain)

true

VWD is the most common inherited bleeding disorder.

true

he risk of developing a ventricular aneurysm is greatest 6 to 10 weeks after suffering an MI.

true

Bottom Line: There are a variety of conditions that can affect the knee. For medial tibial pain near the knee joint, pes anserine bursitis should be considered.

true treat with NSAID

This patient displays the classic presentation of pulmonary embolism (PE), which includes abrupt onset of pleuritic chest pain, shortness of breath, and hypoxia. The Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED) II study listed the following indicators for PE: Travel of 4 hours or more in the past month Surgery within the past 3 months Malignancy, especially lung cancer Current or past history of thrombophlebitis Trauma to the lower extremities and pelvis during the past 3 months Smoking Central venous instrumentation within the past 3 months Stroke, paresis, or paralysis Prior pulmonary embolism Heart failure Chronic obstructive pulmonary disease The risk for a thromboembolic event increases when tumescent liposuction is performed with other concurrent surgical procedures. Computed tomography (CT) angiography (CTA) is the first-line imaging test for the assessment of patients with suspected acute PE in daily clinical practice. A CTA is simply a routine chest CT with thinner collimation (2 mm) and an arterial contrast bolus. There is nothing different about the study compared to the routine unenhanced CT except those 2 parameters.With a CT, a specific cause for the patient's symptoms and important additional diagnoses can be established in many cases. In addition, not only intravascular thromboembolic filling defects, but also other manifestations of precedent pulmonary thromboembolism, including parenchymal infarction, pleural effusion, vascular remodeling (dilation, pouches, thrombotic wall thickening), and oligemia, can readily be visualized with CTA. CTA also appears to be the most cost-effective modality in the diagnostic algorithm of PE. Viscerosomatic reflexes are a type of somatic dysfunction caused by changes in the autonomic nervous system. They can be acute or chronic and are considered to be a somatic representation of visceral disease. When either branch of the autonomic nervous system (sympathetic or parasympathetic) overstimulates a particular organ, a reflex reaction occurs. The soma at the same level of the organ's autonomic innervation takes on characteristics of somatic dysfunction (TART). T2-T7 is where the sympathetic viscerosomatic reflex for the pulmonary system is located.The osteopathic findings described also illustrate chronic findings in somatic dysfunction, versus acute changes. Acute and chronic somatic dysfunction findings differ in tissue texture changes, restriction, and tenderness. In patients with chronic somatic dysfunction, the tissue texture changes are cool, dry, flaccid, ropy, and fibrotic. The restriction is present, but there is decreased or no pain. Tenderness in chronic somatic dysfunction is described as dull, achy, and burning. Acute tissue texture changes are edematous and erythematous, with increased tonicity of muscles. The restriction is present and is painful with movement. Acute tenderness is described as severe and sharp.

true Computed tomography angiogram of the chest should be performed in patients with a high suspicion of pulmonary embolism.

Lifestyle modifications in patients with heart failure include, salt restriction, fluid restriction (if sodium is low or their fluid balance is difficult to control), weight loss if overweight, regular physical activity, and annual vaccinations.

true To get credit for this question you needed to have chosen annual vaccinations (all patients, not just heart failure patients should have these), regular physical activity, and salt restriction. Increasing salt intake would be inappropriate and would lose you points on this question. Lifestyle modifications in patients with chronic systolic heart failure and symptoms or previous heart failure exacerbation include salt restriction, fluid restriction if the patient's sodium is < 130 or they have difficult to control fluid balance, weight loss if overweight, regular physical activity, and annual vaccinations. If the patient is underweight, the guidelines recommend caloric supplementation. If the patient has known heart failure on echocardiogram but has never had symptoms, then risk factor modification is preferred, which would include treating hypertension and hyperlipidemia, smoking, illicit drug, and alcohol cessation, and control of diabetes if present. All of these should also be addressed in a patient with chronic heart failure.There is very little evidence for the use of salt restriction in heart failure, and currently, there are efforts by the American Heart Association among others to have a randomized-controlled trial on the use of salt restriction in heart failure. However, at this time, moderate salt restriction is recommended. Some small studies have shown worse outcomes with salt restriction in the absence of ACEI or other neurohormonal blockade. It is theorized that activation of the renin-angiotensin system by salt restriction without ACEI/ARB use can cause worsening decompensation. However, for your test, remember that currently moderate salt restriction is recommended at least until a randomized trial is completed.

After conservative treatments have failed, ------can be used to stop postpartum hemorrhage in stable patients.

uterine artery embolization

Hydatidiform moles increase the risk of ---

uterine rupture.

The Chapman point for the ----is found at L5 and medial to the posterior superior iliac spine (PSIS).

uterus

------ X-linked dominant inheritance include: Rett syndrome and incontinentia pigmenti.

x-liked dominant

Acanthamoeba infection

--------- is associated with poor care of contact lenses, but this is not the most likely diagnosis as acanthamoeba infection is quite rare. Acanthamoeba infection of the eye is a very rare infection that occurs in patients who do not clean their contact lenses properly. It can present with painful red eyes and can be treated with propamidine with polymyxin ophthalmic solution. This question asks for the most likely diagnosis, which is allergic conjunctivitis, as acanthamoeba infection is quite rare and would likely present with a more severe presentation.

During the mild early ingestion of aspirin, what are some of its toxicity? 300-500mg/l

-burning in the mouth -lethargy -Nausea/vomiting -Tinnitus -Dizziness

--------is used to treat carbon monoxide (CO) poisoning. CO poisoning is commonly caused by house fires and automobile exhaust ingestion. It presents with headache and cherry-red skin. Lactic acidosis may also be seen as a result of hypoxia.

100% oxygen is used to treat carbon monoxide (CO) poisoning. CO poisoning is commonly caused by house fires and automobile exhaust ingestion. It presents with headache and cherry-red skin. Lactic acidosis may also be seen as a result of hypoxia.

Bottom Line: Infective endocarditis treatment duration varies largely upon native vs. prosthetic valve and organism. S. aureus, both MSSA and MRSA, requires an empiric duration of ------

6 weeks of parental therapy. Duration varies by organism and valve status, with the shortest being 2 weeks of IV therapy for highly susceptible organisms such as Streptococcal viridans species on native valves to 6 weeks for all types of S. aureus, including oxacillin-susceptible or resistant Staphylococcus aureus (MRSA). While it is impractical to test on all combinations, as S. aureus is a frequent cause of endocarditis and duration is the same regardless of antibiotic resistances, it is a must know both academically and clinically. Antibiotic regimen, although not tested in the question, utilizes treatment with nafcillin or cefazolin, each as monotherapy for MSSA. If MRSA is isolated, vancomycin or daptomycin may be used. If the patient has prosthetic valve endocarditis, both rifampin and gentamicin must be added in combination with either Oxacillin/Nafcillin for MSSA and Vancomycin or Daptomycin for MRSA for at least the initial two weeks of therapy. If cultures do remain positive after empiric durations, additional seeding including diskitis or abscess formation should be ruled out.

Retrograde urethrogram is the gold standard for diagnosing urethral injury. Signs include blood at the meatus and a high riding prostate. A foley catheter should only be placed by a urologist if a urethral injury is present following the retrograde urethrogram.

A retrograde urethrogram is performed by injecting contrast into the urethra while taking a radiograph. Extravasation of the contrast outside of the urethra indicates a urethral injury. A urethral injury should be confirmed by retrograde urethrogram prior to consulting urology.

A 39-year-old female presents to the emergency department with abnormal bleeding from the uterus. After a thorough workup, the patient is ultimately diagnosed with dysfunctional uterine bleeding (DUB). he underlying cause for her uterine bleeding is most likely due to the unopposed production of? A-estradiol B-estrone C-Follicel-stimulating hormone D-Luteinizing hormone E-Progesterone

A-estradiol Dysfunctional uterine bleeding (DUB) is a diagnosis of exclusion that is made when other etiologies such as inflammation, tumor, and pregnancy are ruled out. Approximately 90% of all cases are thought to occur from anovulatory cycles due to the unopposed production of estradiol.

A 41-year-old female presents to your office for her routine Pap smear. The procedure is performed without complication and the specimen is sent for examination. Several days later her lab report arrives at your office and describes atypical squamous cells of undetermined significance. The most appropriate next step in the management of this patient should include: A. HPV testing B. increased frequency of Pap smears to every 3 months for one year C. continuation of yearly pap smears as well as HPV testing D. cryotherapy of the cervix E. reassurance and followup in 5 years

A. HPV testing Atypical squamous cells of undetermined significance (ASC-US) can be managed in 2 ways. The first option is to repeat cytology in one year and perform colposcopy if follow-up smears are abnormal. The second option is to perform an HPV test and return for testing in 3 years if it is negative or perform colposcopy if HPV test is positive. The most preferred method is to perform an HPV test.

A newborn develops bilateral reddening of the conjunctiva in the nursery 2 hours following birth. There is no purulent drainage, and the child is afebrile. The most likely diagnosis is: A. chemical reactive conjunctivitis B. congenital cataract C. gonorrheal conjunctivitis D. inclusive conjunctivitis E. strabismus

A. chemical reactive conjunctivitis

AD, or eczema,

AD, or eczema, is a chronic inflammatory skin disorder that is best treated, initially, with a short course of topical corticosteroids. PUVA treatment can be used in the treatment of mild, moderate, and severe AD; however, it would be a more expensive choice than topical corticosteroids. In addition, PUVA has been shown to mildly increase the risk of long-term carcinogenicity. Topical immunomodulators (e.g., tacrolimus) are indicated for long-term and short-term therapy of moderate to severe AD. It is considered a second-line treatment for children who have failed topical corticosteroid therapy. Thus, in addition to the expense, this would not be a first-line treatment option.

?might be necessary in patients who have failed or declined hormonal therapy, who have symptomatic anemia, and who experience a disruption in their quality of life from persistent, unscheduled bleeding.

Abdominal or vaginal hysterectomy

Corneal ulcers can be a result of bacterial keratitis, viral keratitis, fungal keratitis, protozoan keratitis, or non-infectious keratitis. Bacterial keratitis is usually the result of disruption in the corneal epithelium. This may be due to contact lens wear, immunosuppression, contamination of topical medication, trauma, or aggressive hyperacute form of conjunctivitis such as that from gonococci. Viral keratitis is usually from a herpetic dendrite. Fungal keratitis may be caused by disruption of the corneal epithelium by vegetative matter, contact lenses, or fingernail trauma. Certain protozoans, such as ???, can occur from poor contact lens hygiene.

Acanthamoeba

----- is a potential complication of macrolide antibiotics such as erythromycin.

Acute cholestatic hepatitis

while there are several definitions for metabolic syndrome the ATP III criteria is most widely used. The ATP III criteria define the metabolic syndrome as the presence of any three of the following five traits: -Abdominal obesity, defined as a waist circumference ≥102 cm (40 in) in men and ≥88 cm (35 in) in women -Serum triglycerides ≥150 mg/dL (1.7 mmol/L) or drug treatment for elevated triglycerides -Serum high-density lipoprotein (HDL) cholesterol < 40 mg/dL (1 mmol/L) in men and < 50 mg/dL (1.3 mmol/L) in women or drug treatment for low HDL cholesterol -Blood pressure ≥130/85 mmHg or drug treatment for elevated blood pressure -Fasting plasma glucose (FPG) ≥100 mg/dL (5.6 mmol/L) or drug treatment for elevated blood glucose

Adult Treatment Panel III (ATP III) Studies have shown a strong association between the metabolic syndrome and the risk for subsequent development of type 2 diabetes and cardiovascular disease. Diagnosis is important in sorting out patients who need aggressive lifestyle modification focused on weight reduction and increased physical activity. Answer E: LDL is not a component of the criteria for metabolic syndrome.

After an abnormal maternal serum α-fetoprotein screen, the next step is -------to rule out a dating error.

After an abnormal maternal serum α-fetoprotein screen, the next step is ultrasound to rule out a dating error. This pregnant woman has an elevated α-fetoprotein. A common cause is inaccurate dating, which should be ruled out before seeking a more serious pathology. This can be done with ultrasound. Ultrasound can also help rule out other causes including twin gestation and placental abnormalities.

Match the following case items(renal diagnoses with their correct corresponding headings(disease characteristics). Answers may be used once, more than once, or not at all. A 12-year-old boy develops gradual symptoms of persistent microscopic hematuria and bilateral high-frequency sensorineural hearing loss. A) Alport's syndrome B) Goodpasture's syndrome C) Granulomatosis with polyangiitis D)IgA nephropathy E) Post-infectious glomerulonephritis

Alport's syndrome A 12-year-old boy develops gradual symptoms of persistent microscopic hematuria and bilateral high-frequency sensorineural hearing loss. A 12-year-old boy develops gradual symptoms of persistent microscopic hematuria and bilateral high-frequency sensorineural hearing loss.

Bottom Line: A prostate nodule on digital rectal examination or serum prostate-specific antigen >10 ng/mL makes prostate biopsy your next step in management.

Although screening for prostate cancer is controversial, the American Cancer Society recommends (for men who choose screening) prostate-specific antigen (PSA) testing with or without digital rectal exam (DRE) for average-risk men beginning at age 50. Although this patient is asymptomatic, there was a prostate nodule on exam and his PSA was >10 ng/mL. Biopsy is the next step for either a nodule on exam or if the serum PSA is >10 ng/mL. For PSA of 4 to 10 ng/dL, biopsy is usually recommended regardless of DRE findings because 1 in 5 biopsies will reveal cancer. For PSA <4 ng/mL, management is less clear as most patients have negative biopsies. This is an example of a case where biopsy or serial PSA levels would be appropriate. A rate in the rise of serum PSA >0.35 ng/mL per year (when baseline PSA is <2.5 ng/mL) would be an indication for biopsy.

He continues to have constipation despite the use of stool softeners. On defecation, he notes a tearing pain and now occasional blood on the toilet paper when he wipes. On exam, he has a tear in his anoderm distal to the dentate line. What is the most likely diagnosis?

Anal Fissure Tears in the anal mucosa are common and generally heal with only conservative management.

------- is the rarest of the thyroid cancers. It spreads and metastasizes rapidly. Prognosis is extremely poor, with 10% survival after 3 years.

Anaplastic thyroid carcinoma

Angiotensin-converting enzyme inhibitor or angiotensin receptor blocker therapy should be initiated in a hypertensive patient with advanced chronic kidney disease and/or significant albuminuria.

Answer E: There is room to increase his hydrochlorothiazide; however, given that he has noted renal disease and albuminuria due to hypertensive nephropathy, he should be started on an ACEI or ARB instead.

--- drugs are a common cause of delirium in the elderly.

Anticholinergic This elderly patient is experiencing delirium, an acute onset of altered consciousness and cognitive decline. Anticholinergic drugs, such as benztropine, are a common cause of delirium in the elderly. Many other drugs may cause it as well, such as diphenhydramine and tricyclic antidepressants. Medical conditions must also be ruled out as the cause. Haloperidol is used to treat anxiety and hallucinations in the elderly. Short-term use may be helpful in delirium.

A 62-year-old male with known atherosclerosis presents with weakness and loss of pain and temperature sensation with relative sparing of position and vibratory sensation. You answered this question correctly. A. amyotrophic lateral sclerosis B. anterior spinal artery syndrome C. Brown-Sequard syndrome D. syringomyelia E. vitamin B12 deficiency

B. anterior spinal artery syndrome Anterior spinal artery syndrome is a disorder affecting the corticospinal tract, spinothalamic tract, ventral horn of the spinal cord, and lateral gray matter. Dorsal columns are spared. This condition is highly associated with atherosclerotic aneurysms of the aorta. Patients present with bilateral loss of pain and temperature and spastic paresis below the lesion with bilateral flaccid paralysis at the level of the lesion.

-----results from inadequate intake of thiamine. There are 2 primary forms: wet (cardiovascular in origin and presenting with edema) and dry (peripheral and central nervous system dysfunction). Infantile beriberi occurs in breastfed infants whose mothers have a thiamine deficiency. Infants will present with constipation, crying, restlessness, and vomiting. Severity varies greatly. Failure to thrive and sudden infant death are also well-known outcomes of thiamine deficiency.

Beriberi

presents with anterior shoulder pain that is 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.

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 nonsteroidal anti-inflammatory drugs (NSAIDs). When conservative treatments fail to relieve the patient's pain, corticosteroid injection into the bicipital groove is indicated.

Trendelenburg gait

Bottom Line: A Trendelenburg gait is caused by weakness of the hip abductors. The gluteus medius is the primary abductor, and it is innervated by the superior gluteal nerve (L4-S1).

Bottom Line: Atrial fibrillation with rapid ventricular response can be initially managed with calcium channel blockers or beta-blockers in -----------

Bottom Line: Atrial fibrillation with rapid ventricular response can be initially managed with calcium channel blockers or beta-blockers in stable

Answer C: Bronchiectasis, which is characterized by permanent dilation of the small and medium bronchi secondary to the destruction of the bronchial elastic components, classically presents with productive cough, hemoptysis, frequent respiratory infections, and copious amounts of sputum. This is a diagnosis based on imaging findings and is often associated with chronic lung infection.

Bottom Line: The classic description of a patient with emphysema is a thin patient with a pink complexion, or a "pink puffer." This is in contrast to the classic chronic bronchitis patient, who is often edematous and cyanotic appearing, or a "blue bloater."COMBANK Insight : You can pretty much guarantee that you are going to see ALL of the above answer choices in different scenarios on your exam day. We cannot emphasize enough how important it is that you are able to diagnose, work up, and treat these lung conditions.

Brain abscesses be evaluated by -----

Brain abscesses present with the classic triad of headache, fever, and focal neurologic deficit and should be evaluated by neurosurgery for drainage.

Epstein-Barr virus is associated with

Burkitt lymphoma and nasopharyngeal carcinoma. nasopharyngeal carcinoma. Classically, it affects adults in southern China, children in Africa, and the Arctic Inuit population. It is often widespread to lymph nodes at the time of diagnosis and is highly associated with Epstein-Barr virus (EBV). In fact, 100% of nasopharyngeal carcinomas contain EBV DNA. They grow silently, usually until they are unresectable. Radiotherapy is the standard treatment. Clonal EBV DNA is found in 100% of nasopharyngeal carcinoma. Burkitt lymphoma (B) is a B-cell lymphoma that is one of the most common childhood tumors in Africa and New Guinea and is also associated with EBV.

A 45 year old female develops persistent rhinitis, cough and shortness of breath. She complains of an unintentional weight l0oss over the past 3 months. Chest x-ray and tuberculosis testing are unremarkable. Urinalysis shows red cell casts. A kidney biopsy is performed showing rapidly progressive glomerulonephritis. The patient eventually progresses to chronic renal failure. What is the most likely diagnosis A) Alport's syndrome B) Goodpasteur's syndrome C) Granulomatosis with polyangitis D) IgA nephropathy E) Post-Infectious Glomerulonephritis

C) Granulomatosis with polyangiitis Granulomatosis with polyangiitis (GPA) is one of the various ANCA (antineutrophil cytoplasmic autoantibody) vasculitides. The most widely accepted definition is found in the 2012 International Chapel Hill Consensus Conference on the Nomenclature of Vasculitides: necrotizing granulomatous inflammation usually involving the upper and lower respiratory tract, necrotizing vasculitis affecting small to medium vessels, and commonly, necrotizing glomerulonephritis. The pathogenesis of GPA is complex and multifactorial, including infectious, genetic, pharmaceutical, and environmental factors. Patients typically have nonspecific symptoms such as fever, joint pain, rhinitis, shortness of breath, cough, and urinary abnormalities. Patients may have a prodrome of constitutional symptoms, including weight loss. These can be chronic or more acute depending on patient presentation. Signs of glomerulonephritis and upper or lower airway bleeding due to necrosis may or may not be present. Diagnosis usually begins with a thorough history and physical exam, along with ANCA testing, if GPA is suspected. As much as 94% of patients with GPA will have a positive ANCA test. Urinalysis may show sediment, and red cell casts. Biopsy of the organ thought to have active disease is common, typically of the kidneys and lungs, but treatment is recommended prior to biopsy confirmation if suspicion is high. Nasal biopsy has a high false positive rate. Renal biopsy or lung biopsy can confirm the diagnosis if it is in question. Treatment consists generally of systemic glucocorticoids and other immunosuppressive therapies. Bottom-line Granulomatosis with polyangiitis (GPA) is a type of ANCA vasculitis that presents in various ways, though persistent URI symptoms (e.g. rhinitis) is the initial presenting symptom in most cases. Level 3 exams tends to test classic presentations of many diseases, especially renal disorders.

Orbital cellulitis can be a vision-threatening condition, and either a ----- or ---- should be ordered to determine whether an abscess has formed.

CT scan or MRI In the absence of abscess formation, IV antibiotics and admission to the hospital are the preferred treatment for orbital cellulitis.

-------, is used when the patient is making no respiratory effort--the machine does not allow spontaneous breaths, nor does it support them. This is a total ventilator-dependent setting.

Controlled mechanical ventilation, or CMV

----------- are defects that involve the corneal epithelium resulting in pain, tearing, photophobia and possible blurry vision. The cornea consists of five layers with the most superficial being the epithelium followed by Bowman's layer, stroma, Descemet's layer, and endothelium. Defects in the cornea past the epithelium into the Bowman's layer will result in permanent scarring. Defects limited to the epithelium will heal within 48-72 hours, as the corneal limbal stems push new epithelial cells centrally. The

Corneal abrasions

The Chapman's point for the terminal ileum and ileocecal area

Crohn disease most often affects the terminal ileum (with or without colon involvement). The Chapman's point for the terminal ileum and ileocecal area is at the right proximal femur.

A 28-year-old Caucasian female, G2P1, with a past medical history of pre-eclampsia and hypertension, presents to the hospital at 34 weeks gestation with a four-day history of nausea, vomiting, mild right upper quadrant pain accompanied by generalized fatigue. Her pregnancy to date has been otherwise uncomplicated with routine prenatal care. Physical examination reveals a pulse of 104/min, a blood pressure of 150/90 mmHg, and vague right upper quadrant pain upon palpation. Laboratory results reveal a normal white blood cell count, with decreased hemoglobin. The platelets are 46 x 103/mcL (reference range: 130-400 x 103/mcL) and her AST is 80 U/L (reference range: 10-59 U/L). She has trace urine protein on dipstick. Based on this information, the most likely diagnosis is A. acute fatty liver of pregnancy B. acute hepatitis C. appendicitis D. HELLP Syndrome E. preeclampsia

D. HELLP Syndrome HELLP syndrome is a late complication in pregnancy defined by hemolysis, elevated liver enzymes, and low platelets. The clinical scenario may be similar to preeclampsia (proteinuria and elevated blood pressure), but these findings are not required for diagnosis. It likely represents a severe form of preeclampsia; however, the association is still controversial. The etiology is unknown, but clinical manifestations are explained by vasospasm which leads to hemorrhage and organ necrosis. Risk factors include nulliparity, African American ethnicity, extremes of age (< 20 or >35), multiple gestation, molar pregnancy, renal disease, previous HELLP or pre-eclampsia, and chronic hypertension. Treatment is supportive care until delivery. Hypertension is controlled in a similar way as in preeclampsia, usually with labetalol, hydralazine, or nifedipine or, in severe cases, with sodium nitroprusside. Magnesium sulfate is also given to prevent convulsions and to for neuroprotection of the fetus for patients between 24-32 weeks gestation. Delivery is the only curative treatment. After the mother is stabilized, delivery is indicated for: pregnancies >34 weeks or < 23 weeks gestation, fetal demise, nonreassuring fetal tests, or severe maternal disease. Additional supportive care may include steroids and platelet transfusion.

A 49-year-old female presents to the hospital with recurrent symptoms of weight loss, depression, and a yellowish discoloration of her skin. Her liver is palpable three fingerbreadths below the right costal margin. There is a posterior Chapman's reflex point located at the right T7 intertransverse space. The patient is noted to have ascites on ultrasound of the abdomen. The most sensitive test to detect carcinoma of the pancreatic head is: A. abdominal plain films B. carcinoembryonic antigen C. colonoscopy D. endoscopic retrograde cholangiopancreatography E. palpation of the abdomen

D. endoscopic retrograde cholangiopancreatography Bottom Line: Endoscopic retrograde cholangiopancreatography (ERCP) is the most sensitive test for cancer localized to the head of the pancreas.COMBANK Insight : Patients presenting with obstructive jaundice show significant elevations in bilirubin (conjugated and total), alkaline phosphatase, gamma-glutamyl transpeptidase, and to a lesser extent, aspartate aminotransferase and alanine aminotransferase.

The prevalence of diabetes in this Arizona Native American population has decreased from 69% in 1995 to 50% in the present study. How will a decrease in prevalence affect the sensitivity and positive predictive value of the new HbA1c screening test? A. decreased sensitivity and decreased positive predictive value B. increased sensitivity and increased positive predictive value C. increased sensitivity and no change in positive predictive value D. no change in sensitivity and decreased positive predictive value E. no change in sensitivity and increased positive predictive value

D. no change in sensitivity and decreased positive predictive value Bottom Line: Decreasing the prevalence of a disease in a population decreases the positive predictive value, increases the negative predictive value, and has no effect on either the sensitivity or specificity of a diagnostic or screening test.

A 26-year-old female, G2P1, at 27 weeks gestation presents to the obstetric office after experiencing symptoms of new onset right calf swelling. A duplex ultrasound is obtained which shows a deep venous thrombosis (DVT) within the popliteal vein. The most appropriate treatment for this condition is A. intravenous unfractionated heparin B. no treatment is indicated C. placement of an inferior vena cava filter D. subcutaneous low molecular weight heparin E. warfarin

D. subcutaneous low molecular weight heparin Bottom Line: Low molecular weight heparin is the treatment of choice for acute deep vein thrombosis in pregnancy.

-----refers the opening of a wound along a surgical suture line resulting in increased serosanguinous drainage and impaired wound healing.

Dehiscence

This elderly woman is presenting with acute delirium.The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) lists the following criteria for delirium: 1. Disturbance in attention and awareness 2. Mental status change from baseline that develops rapidly (ie, hours to days) and fluctuates over the day 3. An additional disturbance in cognition (eg, change from baseline in memory, orientation) 4. The disturbance is not better explained by a preexisting neurocognitive disorder 5. There is evidence from the history and physical exam that the mental status change is caused by a medical condition (eg, acute symptomatic urinary tract infection), medication intoxication or withdrawal, or medication side effect Additional features can include: 1. Psychomotor disturbance including increased or decreased activity level from baseline or acute sleep disturbance 2. Emotional disturbance (eg, increased fear, suspicion, depression, euphoria)

Delirium is the acute onset of cognitive impairment and altered consciousness due to an underlying medical condition. Polypharmacy and medication misuse are common causes in the elderly.

-----wounds are those that contain devitalized, necrotic tissue. These wounds also include surgical sites in which there has been a perforation present before the start of the surgery. This category also includes wounds that have been grossly contaminated by stool.

Dirty wounds

A first trimester combined screening test is performed and reveals markedly elevated Beta-HCG, decreased PAPP-A, and increased nuchal translucency on ultrasound. what do you suspect this infant has?

Down Syndrome A patient with a positive screening test should be offered secondary screening using maternal cell-free DNA. or invasive testing with chorionic villus sampling or amniocentesis. Maternal cell-free DNA still caries a high false positive rate, and for patients who wish for the most definitive and expeditious test, a chorionic villus sampling should be offered.

-------- is caused by diffuse palmar fascia thickening, which leads to flexion at the MCP, PIP, and DIP joints and the inability to fully extend the digits. These contractures are typically painless in nature.

Dupuytren contracture

E) Post-infectious glomerulonephritis Match the following case items(renal diagnoses with their correct corresponding headings(disease characteristics). Answers may be used once, more than once, or not at all.

A 19-year-old pregnant patient presents for her initial prenatal visit. Based on her last menstrual period, she guesses she is about 18 weeks' gestation. Physical exam reveals a painless localized ulcer on the left labia minora. Initial screening serologies for infectious diseases are sent. Which of the following is the most likely infectious agent, and what is the most appropriate choice in management? A. Chlamydia trachomatis; oral macrolide B. Haemophilus ducreyi; oral fluoroquinolone C. human papillomavirus; topical immunomodulato D. Neisseria gonorrhoeae; oral cephalosporin E. Treponema pallidum; intramuscular penicillin

E. Treponema pallidum; intramuscular penicillin Primary syphilis, caused by the spirochete Treponema pallidum, typically presents with a painless ulcer, known as a chancre, as presented in this case. Primary syphilis generally occurs 6 weeks following exposure or close contact with an infected sexual partner, and development of the painless chancre (most often occurring on the genitals). The chancre will heal if left untreated; however, it is vital to treat while at this stage to prevent the development of secondary and tertiary syphilis and the related consequences.Secondary syphilis typically presents months later with scaly patches on the body, including palms and soles, plus systemic findings such as fever, malaise, muscle aches, and/or lymphadenopathy. Latent and finally tertiary syphilis will result, causing potential neurologic and/or cardiac manifestations if untreated. Screening for syphilis is routine when receiving adequate prenatal care and is accomplished with a rapid plasma reagin (RPR) or venereal diseases research laboratories (VDRL) serologic test. These are nontreponemal tests.Confirmatory testing (treponemal tests) includes dark-field microscopy or direct fluorescent antibody (DFA) tests. Treatment of primary syphilis is with a single dose of intramuscular Penicillin G, and in penicillin-allergic pregnant patients, desensitization should be offered in an ICU setting prior to administration. Treating this patient for syphilis is best for her and her unborn child, as syphilis is one of the TORCH family of congenital infections. Congenital syphilis can have serious consequences to the unborn fetus, including bony abnormalities (saber shin, saddle nose), Hutchison's teeth, and sensorineural hearing loss. Chlamydia is caused by the obligate intracellular pathogen Chlamydia trachomatis and does not cause a chancre as described in the question stem. It is more likely to cause pelvic inflammatory disease or urethritis, but may be asymptomatic initially in females. Serum and urine nucleic acid amplification tests are available for diagnosis. An oral macrolide treatment is acceptable, generally as a single 1-gram dose of azithromycin, which is pregnancy category B. B: Chancroid is caused by the gram-negative facultative anaerobe Haemophilus ducreyi. Chancroid lesions resemble those of primary syphilis but are painful. These are also treated well by a single dose of an oral macrolide. Human papillomavirus is the causative organism behind venereal warts. While warts may be treated, many of the available treatments are pregnancy class C, and the benefit of treating active warts must be weighed against the risk. Active genital warts may transmit infection to the infant during birth, but this is rare. Answer D: Gonorrhea is caused by Neisseria gonorrhoeae, gram-negative diplococci bacteria that also do not produce ulcerations. This organism is more likely to cause urethritis or pelvic inflammatory disease and also may be asymptomatic initially in females. It is treated with oral or intramuscular cephalosporins. Risk to the infant is usually ocular disease, which is universally treated with prophylactic erythromycin following birth.

A 57-year-old African American male with no past medical history presents to his primary care physician's office after experiencing episodic chest pain. The patient describes 2 weeks of substernal pressure that is typically worse overnight and in the morning and lasts for somewhere between 10 and 20 minutes before subsiding. It is unchanged by when or what he eats. He almost never has chest pain during the day. He is a long-time runner and runs between 3 and 5 miles 4 times a week without symptoms. Upon physical examination, cardiopulmonary auscultation is unremarkable. His lungs are clear. He denies a history of gastroesophageal reflux disease or other abdominal upset and has no history of heart disease. An electrocardiogram during symptomatic periods would most likely show A. delta waves throughout all the leads B. Q waves throughout the precordial leads C. sustained ST-segment depression D. sustained ST-segment elevation E. transient ST-segment elevation

E. transient ST-segment elevation This case describes a patient presenting with classic symptoms of coronary artery vasospasm, also known as variant or Prinzmetal angina. An electrocardiogram (ECG) obtained during symptomatic events would show transient ST-segment elevation or depression, which would resolve with the use of nitrates. The key to this question is understanding the way coronary artery disease presents. Commonly, chest pain is worse with activity and relieved by rest. The fact that this patient's pain starts at rest and is not associated with activity should be a clue. In addition, if he had significant, symptomatic coronary artery disease, it would be highly unlikely that he could run without symptoms. These factors together make vasospasm much more likely.The etiology of coronary spasm is unknown in the majority of patients; certain triggers such as cocaine, tobacco, and hyperventilation have been linked to spasm. Transient ST-segment elevations or depressions are a common finding in cases of variant angina, which classically presents as substernal chest pressure at rest, generally appearing overnight or in the early morning hours. The workup must rule out any possibility of underlying coronary artery disease with myocardial perfusion imaging or even coronary angiography. The diagnosis of vasospasm is confirmed if the patient's ECG changes resolve with nitrates or if spasm is seen on coronary catheterization.

what are some appropriate labs and imaging to order in someone with chest pain

ECG, Troponin, orthostatic vitals, cxr note:Creatine kinase (CK) and its MB isoenzyme (CK-MB) were the most commonly used serologic tests for the diagnosis of myocardial infarction prior to the widespread adoption of troponin. Their use has markedly diminished over time and would not be drawn in today's emergency department or clinic due to lack of utility. If there was concern for active ischemia then a troponin I measurement would be the best laboratory test. On the COMLEX CDM cases, be wary of invasive or expensive testing when performing an initial workup as generally, unless strongly indicated, those will be the tests that lose you points. for example a cheap test that won't cost much will be orthostatics- so one can opt to get it done. a multivitamin would not improve the patient's GERD, but because it is cheap and not harmful, recommending one would not get you this question incorrect.

------- This act requires that a hospital provide emergency services, regardless of a patient's status or ability to pay.

EMTALA is the Emergency Medical Treatment and Active Labor Act.

Bottom Line: The most common injury to the pectoralis major muscle during bench press occurs during deceleration towards the chest. This is known as an eccentric contraction. During eccentric contraction the muscle is lengthening despite actively contracting. This causes minor muscle damage under normal circumstances (which when repaired causes strength gains), however, in the setting of too heavy of a load or muscular insufficiency this can result in severe injury.

Eccentric muscle contraction occurs when a muscle increase in length with contraction. It is a great tool in strengthening and rehabilitation. Eccentric muscle contractions occur when a muscle increases in length with contraction. The muscle elongates while under tension due to the resistance of the weight being greater than the force generated. This can be seen in the biceps muscle in the lowering motion of a bicep curl. Eccentric exercises have been found to be helpful in treating tendinopathies, specifically achilles.

Electrolytes, creatinine, blood urea nitrogen (BUN), and fractional excretion of sodium (FENa)

Electrolytes, creatinine, blood urea nitrogen (BUN), and fractional excretion of sodium (FENa) need to be monitored in this patient, but they are not the main factors determining replacement fluids during stabilization treatment.

------typically presents with dysmenorrhea, dyspareunia, and nonspecific symptoms, including generalized malaise, fatigue, and disturbances in the normal sleep pattern.

Endometriosis

------- refers to the removal of the eye from the orbit while preserving all other orbital structures. Enucleation is indicated for treatment of painful eyes with no useful vision, malignant intraocular tumors, in ocular trauma to avoid sympathetic ophthalmia in the second eye, in phthisis with degeneration, and in congenital anophthalmia or severe microphthalmia to enhance development of the bony orbit.

Enucleation

The most common organism found in infected bile is -----

Escherichia coli. The most likely organism that is found in infected bile is Escherichia coli. The second most common organism is Klebsiella. The third most common organism is Enterobacter species. The most common gram-positive organism that is found is Enterococcus. Staphylococcus aureus is not commonly found in the gastrointestinal or hepatobiliary tract. It is more commonly an organism found in skin infections. The most common bacteria isolated from infected bile are usually of colon origin.

------is, by far, the most radical of the three procedures and describes the removal of the eye and adnexa, along with part of the bony orbit. Exenteration is indicated mainly for large orbital tumors or orbital extension of intraocular tumors.

Exenteration

------ occurs when a large mass of dry stool lodges in the rectum causing chronic constipation. Management is with oral laxatives or manual disimpaction.

Fecal impaction

Risk of progression of scoliosis is impossible to predict with complete accuracy, but guidelines have been made based on natural history studies. Important factors for risk of progression are gender, magnitude of the curve, curve pattern and skeletal maturity at the time of diagnosis as noted by chronologic age, Risser sign or menarchal status in females. Females are 3 to 10 times more likely to have curve progression than males. In addition, patients with curves with greater initial Cobb angles, thoracic curves and patients with markers indicating skeletal immaturity are all at increased risk for progression of the scoliotic curve.

Females, primarily thoracic curves, larger initial curve magnitude and markers than indicate skeletal immaturity are all related to increased risk of scoliotic curve progression.

----- should be given to a patient with beta-blocker toxicity. It works by stimulating adenylate cyclase to produce increased cyclic AMP, which promotes hepatic glycogenolysis and gluconeogenesis, causing a raise in blood glucose levels.

Glucagon

------- affects the lungs and kidneys which leads to nephritic syndrome. Patients present with hemoptysis. Immunofluorescence reveals an IgG and C3 in a linear pattern on glomerular basement membrane. Serum anti-glomerular basement membrane antibodies are present. It is also classified as a type II hypersensitivity reaction.

Goodpasture's syndrome

Bottom Line: HSIL=High-grade squamous intraepithelial lesion (HSIL) is considered a premalignant lesion, and thus an excisional procedure is indicated. The provider may go directly to a LEEP procedure or may first perform a colposcopy.

High-grade squamous intraepithelial lesion (HSIL) is considered a premalignant lesion. Management per the American Society for Colposcopy and Cervical Pathology (ASCCP) is an immediate loop electrosurgical excisional procedure (LEEP) or a colposcopy. If a colposcopy is chosen, further treatment depends on the grade of cervical intraepithelial neoplasia. For grade 1 dysplasia found on the colposcopy, the options are to co-test at 12 and 24 months or perform a LEEP. If either of the co-tests shows the HSIL again, then the LEEP should be performed. If the initial colposcopy shows grade 2 or 3 dysplasia, then excision or ablation of the transformation zone is recommended. Human papillomavirus (HPV) testing is not indicated and would not change the course of treatment.

------ also known as Gleevec, is used to treat CML and GI stromal cell tumors. It is a Philadelphia chromosome bcr-abl tyrosine kinase inhibitor. A common side effect is fluid retention, so it should be used with caution in patients with congestive heart failure (CHF) and renal disease.

Imatinib, also known as Gleevec,

------ the esophagus is dilated because the lower sphincter is too tight, thus not allowing the passage of food into the stomach. This also prevents the reflux of acid from the stomach. Therefore, GERD is unlikely in these patients.

In achalasia,

As established in the previous question, this patient has immune thrombocytopenic purpura (ITP). The drug of choice for all adult patients with a platelet count less than 30,000/μL who are symptomatic is prednisone 1 mg/kg/d. Second-line drugs used in treatment of ITP include intravenous immunoglobulin, rituximab, and if necessary, splenectomy. Please refer to references regarding treatment approach algorithm.

In immune thrombocytopenic purpura, if the patient is asymptomatic and the platelet count is >30,000/μL, treatment can be held off. The mainstay of the treatment in symptomatic patients is glucocorticoids (prednisone) and intravenous immunoglobulin. The goal of the treatment is to keep platelets >50,000/μL.

incidence

Incidence is the total number of new cases of a disease diagnosed in a population in a certain period of time (normally 1 year). This represents the likelihood of developing that condition in that period of time. For example, when the statement is made that the incidence of cancer has increased in years past, the statement means that more individuals have developed this condition each year. It is calculated in the following manner: (# of new cases of a disease in a given time) / (total population).

----- inhibits fungal cytochrome P-450-dependent enzymes, thus, inhibiting the production of ergosterol. It can be used as prophylaxis in tinea versicolor infections, but not as an initial treatment. Itraconazole may lead to liver dysfunction, therefore, liver enzymes must be monitored with long-term use.

Itraconazole

Kehr's sign

Kehr's sign is due to pain referred from the diaphragm to the shoulder via the phrenic nerve. The most likely diagnosis in this patient is a ruptured spleen. This patient is complaining of left-sided upper abdominal pain after being kicked in the ribs. The spleen lies under the ninth to eleventh ribs on the left and is susceptible to traumatic rupture. Splenic rupture may also present with left shoulder pain, commonly called Kehr's sign. Kehr's sign occurs in response to blood or fluid accumulation under the diaphragm. This blood or fluid causes irritation of the phrenic nerve, which refers pain to the shoulder.

Keratin pearls and the presence of large, irregular nuclei with coarse nuclear chromatin are seen in cases of well-differentiated squamous cell carcinomas.

------- can be caused by sulfonamides. -------refers to brain damage in infants as a result of increased levels of unconjugated bilirubin. Sulfa drugs can lead to increased bilirubin levels, by displacing it from binding sites on albumin.

Kernicterus Kernicterus

------- presents with congestive heart failure and persistent ST-segment elevations several weeks after an acute myocardial infarction.

Left-sided heart failure presents with dyspnea and rales due to pulmonary edema. The additional finding of persistent ST-segment elevations in the anterior leads makes ventricular aneurysm the most likely diagnosis. This could be confirmed with a chest radiograph, which would show a bulge in the left ventricle, and echocardiogram. This is caused by replacement of the infarcted tissue with scar tissue, which decreases contractility and bulges outward, leading to systolic heart failure. This is most common weeks after an anterior wall infarct. Treatment is based on severity. Insignificant aneurysms go untreated with optimization of medical therapy directed at blood pressure control. Large aneurysms that cause hemodynamic compromise must be surgically resected.

The extensor pollicis longus tendon makes up the third compartment of the wrist and courses around ------. It is not involved in DeQuervain tenosynovitis.

Lister's tubercle

first screen

Measurement of the nuchal translucency is usually performed between 11 and 14 weeks gestation. This test is usually performed in conjunction with maternal serum measurements of PAPP-A and β-hCG. This combination is called a first screen.

------ is a congenital diverticulum (remnant of the omphalomesenteric duct) that presents with an intestinal bulge noted at birth. It presents with painless rectal bleeding or intussusception. Technetium radionuclide scan can be used for diagnosis, but the gold standard is obtaining tissue removed surgically. Remember the rule of 2s: 2 feet proximal to the ileocecal valve, 2 types of ectopic tissue (gastric, pancreatic), 2% of the population, 2 times the number of males as females. usually presents by age 2, about 2 inches long, and 2 cm in diameter.

Meckel diverticulum

Bottom Line: Meningiomas are common intracranial neoplasms that are classified as benign tumors; however, bony destruction and involvement of crucial structures are seen. They arise extra-axially from the arachnoid layer and have a broad dural base. They compress underlying brain instead of invading, which is responsible for the symptoms produced. Management is surveillance in asymptomatic cases, and resection can be performed if clinically warranted.

Meningioma is classified as a World Health Organization (WHO) grade I intracranial neoplasm that arises from the arachnoid meningeal layer. It is a common adult intracranial tumor that is more common in females. An association with radiation therapy and neurofibromatosis type 2 has been noted. Classically, these are slow-growing benign neoplasms; however, they can be involved with bone destruction and orbital pathology. Common symptoms depend on the location of the tumor, as the associated mass effect is responsible for causing symptoms. Meningiomas are extradural in origin and grow slowly, so they will compress underlying brain instead of infiltrating it. Common areas of meningioma growth include the parasagittal falx, skull base, frontal skull, and cavernous area. The basis of treatment depends on the underlying symptoms. Many meningiomas are asymptomatic and can be followed with serial imaging. In the case of surgery, resection of the mass and involved dura is ideal, and any area of involved bone is also resected. The image in the exhibit reveals a large dural-based, sharply defined, space-occupying mass along the left parasagittal vertex with compression of the underlying brain. Calcification is noted along the inferior rim of the mass, and meningiomas are known to calcify. Mild edema is noted in the subcortical white matter inferior to the mass. This is almost a definite diagnosis; however, keeping a differential, such as a granuloma or hemangioma, is beneficial. The approach to intracranial mass depends on the age of the patient, location of the mass, and the characteristics of the imaging modality. Primary brain tumors are seen in children and are common in the infratentorial brain, and metastatic disease is rare. Adults more commonly have primary brain tumors in the supratentorial brain, and metastatic disease is common in the posterior fossa. Metastatic disease makes up 50% of brain masses in adults. Deciding whether the mass is in the brain parenchyma or outside the brain is an important distinction. This is termed extra-axial and intra-axial, and there are certain characteristics of each. Extra-axial masses displace the subarachnoid vessels and typically have a layer of cerebrospinal fluid separating them from the underlying brain, and a layer of cortex is often seen between the mass and the white matter. Intra-axial tumors infiltrate the brain, often causing destruction and edema, and the white matter tracts get displaced as a result of the growing tumor. Many intracranial masses have certain imaging characteristics beyond the scope of this question. However, see the included references for a more detailed approach.

------ is an antibiotic that disrupts DNA and inhibits nucleic acid synthesis. It is most commonly prescribed for bacterial vaginosis, trichomoniasis, rosacea, and Clostridium difficile colitis, among many others. It has no place in the treatment of fungal infections.

Metronidazole is an antibiotic that disrupts DNA and inhibits nucleic acid synthesis. It is most commonly prescribed for bacterial vaginosis, trichomoniasis, rosacea, and Clostridium difficile colitis, among many others. It has no place in the treatment of fungal infections.

Missed abortion

Missed abortion is fetal demise without cervical dilatation or passage of products of conception. The treatment is to wait four weeks for the material to expel, and after that time, misoprostol or dilatation and curettage is indicated.

simvastatin pravastatin fluvastatin Lovastatin are all what intensity statin?

Moderate intensity atorvastatin can be given in a moderate dose 10mg to 20 mg

Hairy cell leukemia is a malignant disorder of well-differentiated B lymphocytes that stain positive with the TRAP (tartrate-resistant acid phosphatase) stain.

Mononuclear cells with abundant pale cytoplasma and cytoplasmic projections are often seen on peripheral blood smear in patients with hairy cell leukemia. Ten percent of patients with HCL will never require treatment because they have a benign disease course. However, treatment should begin when patients become symptomatic or cytopenic. Nucleoside analogs are the initial treatment of choice.

She is treated conservatively and her symptoms fail to improve. A CT scan of the abdomen and pelvis reveals ascites, signs of peritoneal metastasis, liver metastasis, and a 8cm ovarian mass. She is taken to the OR for resection and debulking given failure to resolve her small bowel obstruction. On biopsy there is expression of the gastrointestinal markers CK20 and CDX2 with no expression of CA125. Histology shows complex glandular arrangements with areas of stromal invasion. Which of the following tumors is the most likely cause of this patient's symptoms?

Mucinous ovarian tumors are the most likely type of ovarian cancer to present with small bowel obstruction. Surgery is the initial treatment of choice, provided patients are medically fit. Patients who are not fit for surgery may be given chemotherapy and considered for surgery later.

Mumps presents with fever, malaise, arthralgia, pancreatitis, and parotitis. The pancreas is among the organs affected by infection with the paramyxovirus that causes mumps.

Mumps is caused by an RNA virus of the rubulavirus family, a subset of the paramyxoviruses. It causes a clinical syndrome, which includes fever, malaise, arthralgia, pancreatitis, and parotitis. It can also cause unilateral orchitis, which is less commonly manifested in boys younger than ten years of age. Pancreatitis is a rare manifestation and typically self-resolves within one week of the onset of symptoms. The virus directly infects the epithelium of different tissues, causing a painful inflammatory process. The eyes, testicles, pancreas, and kidneys are among the organs that can be involved.

In myxedema coma, there is increased free water retention due to antidiuretic hormone secretion in the setting of hypotension, resulting in mild hyponatremia and nonpitting edema. There is often a decreased WBC count due to hypothermia, despite the fact that the precipitating event may be an underlying infection. Hypoglycemia is also common.

Myxedema coma is a manifestation of severe hypothyroidism and is confirmed by measurement of the thyroid stimulating hormone (TSH) and thyroxine (T4). It is treated with heating blankets, IV fluids, IV thyroxine, and IV hydrocortisone until concomitant adrenal insufficiency is ruled out.

----is given for opiod intoxication. It is a pure opioid antagonist that competes and displaces opioids at opioid receptor sites. The question stem states that ECG shows QT prolongation and QRS widening which should prompt tricyclic antidepressant overdose. Opioid overdose would lead to QT prolongation and also torsades de pointes in some cases but it is not classic for causing QRS widening.

Naloxone

Patients with NPH have classic symptoms of urinary incontinence, unstable gait, and mental status changes. Findings include normal cerebrospinal fluid opening pressures on lumbar puncture, no papilledema, and enlarged ventricles on imaging.

Normal pressure hydrocephalus (NPH) is the best choice given this patient's symptoms of urinary incontinence, dementia, and gait abnormality, which is often the earliest sign. This triad is known as the Hakim triad. NPH describes hydrocephalus in the absence of papilledema and with normal cerebrospinal fluid (CSF) opening pressure on lumbar puncture. Computed tomography or magnetic resonance imaging of the brain will show ventriculomegaly in the absence of sulcal enlargement. Shunt placement is the best treatment for NPH patients; however, repeated lumbar punctures in combination with acetazolamide may also aid with improvement in symptoms.

------- is the result of infection with Bartonella henselae, a pleomorphic gram-negative bacillus. The pathology is attributed to cat-scratch disease. Patients are typically infected from kittens either through bites and scratches or contact of the eye with the saliva of infected kittens. Patients may also experience fever, fatigue, and malaise. The disease is usually self-limited. Azithromycin is a commonly used drug in persistent cases.

Parinaud oculoglandular syndrome

Phencyclidine hydrochloride (PCP)

Phencyclidine hydrochloride (PCP) causes psychosis and violent behavior and is associated with horizontal and vertical nystagmus. ataxia, and delirium. Benzodiazepines are typically used to treat severe symptoms.

Initial treatment of subacromial bursitis consists of rest, activity modification, physical therapy, and oral NSAIDs. More aggressive treatments, such as corticosteroid injections, are indicated when conservative treatments fail. Subacromial injection is preferred over intra-articular injection because the bursal inflammation is localized to the subacromial space. If symptoms continue to persist, advanced imaging followed by possible surgical intervention may prove necessary.

Physical exam is usually benign but may show a positive Neer's impingement test and a positive Hawkin's test. Subacromial bursitis is initially treated with conservative treatments such as rest, activity modification, oral NSAIDs, and physical therapy. When these conservative treatments fail to provide the patient with pain relief, corticosteroid injections into the subacromial space are indicated. If corticosteroid injections fail to adequately provide pain relief, subacromial decompression is indicated.

The patient has elevated liver enzymes in a cholestatic pattern. The patient's cholangiography demonstrates multifocal structure and dilation ("chain of lakes" pattern) consistent with ?

Primary sclerosing cholangitis majority of patient's with PSC have underlying ulcerative colitis. The prevalence may be up to 90%. Patient's without a diagnosis of UC should undergo colonoscopy to evaluate for IBD. Note: cholangiocarcinoma can develop in patients with primary sclerosing cholangitis. However, it is not as common as ulcerative colitis and it is not the best answer. the lifetime risk of cholangiocarcinoma in patient's with PSC is 10-15% A variety of malignancies are associated with primary sclerosing cholangitis. The most common malignancies are gallbladder cancer and cholangiocarcinoma. Patient's with cirrhosis can also develop hepatocellular carcinoma.

Bottom Line: A patient presenting with a nodule on prostate exam should undergo ultrasound-guided biopsy.

Prostate cancer is the most common cancer in men, and risk increases with age. Most patients are asymptomatic at presentation; however, some may present with urinary urgency, frequency, or hesitancy. The presence of a palpable firm nodule should raise clinical suspicion for malignancy. Diagnosis must be established prior to treatment, and this is accomplished by performing an ultrasound-guided biopsy. Following diagnosis, treatment options can be discussed with the patient.

-------is the most common cause of intestinal obstruction in infancy and occurs when the muscular layers of the pylorus become hypertrophied causing a functional obstruction. These children classically present with nonbilious projectile vomiting, and treatment involves pyloroplasty.

Pyloric stenosis

Hypercalcemia is associated with multiple myeloma and causes shortening of the ---interval.

QT --Hypercalcemia is a known electrolyte disturbance in patients with multiple myeloma. Hypercalcemia may produce EKG findings related to altered conduction time. Shortening of the QT interval is the most common finding.

-------- is when an idea or feeling is unconsciously replaced by its opposite thought. An example is when a heterosexual individual is hateful toward those who identify themselves as homosexual. This person seeks to counteract their deep-seated and often untouched homosexual desires.

Reaction formation

------- implies negligence. It is a term meaning "the thing speaks for itself" and refers to situations where persons suffer injury caused by the action of another party that would not have otherwise occurred. Follow-up x-rays identified the scalpel, requiring no further explanation, as there is no excuse for this action. Res ipsa loquitur also requires that the negligent event that occurred was solely under the defendant's (in this case, the surgeon's) control, and that the plaintiff (the patient) did not at all contribute to the cause.

Res ipsa loquitur

right upper quadrant pain, fever, jaundice, new onset confusion, possible septic shock

Reynolds pentad diagnosis is ascending cholangitis treatment is hydration, intravenous antibiotics and endoscopic biliary drainage followed by cholecystectomy severe symptoms demand emergency bile duct decompression and relief of obstruction Zosyn is a single agent that can cover ascending cholangitis. other combination agents will be ciprofloxacin and metronidazole ceftriaxone and metronidazole

-----should be suspected in patients who present with severe pruritis of the upper extremities and S-shaped tracks on the skin surface with multiple scabs.

Scabies Severe persistent itching greater than two weeks is highly suspicious for scabies infection. The presence of nocturnal pruritus makes the diagnosis even more likely. Short elevated wavy channels on the superficial epidermis (burrows) are pathognomonic for scabies infection. The arthropod Sarcoptes scabiei is responsible for causing the infection. Topical permethrin cream is the drug of choice for the treatment of scabies in the U.S.

SABA

Short-acting bronchodilator inhalers available in the United States include: Albuterol (AccuNeb, Proair HFA, Proventil HFA, Ventolin HFA, also available as a generic solution for nebulizers) Metaproterenol, available as a generic solution for nebulizers. Levalbuterol (Xopenex HFA) Pirbuterol (Maxair)

most common organism that causes acute epiglottitis in adults is -----

Streptococcus pneumoniae.

Dupuytren contracture is also a common cause of locking of the digits, especially in diabetic patients. However, it does not commonly present with a firm nodule. Dupuytren disease is caused by a thickening of the palmar fascia and most commonly affects the fourth and fifth digits.

TRUE

Hirschsprung disease is due to absence of autonomic innervation of bowel in the rectum which causes loss of peristalsis and obstruction. Hirschsprung disease is more common in males. The condition typically presents during the neonatal period and patients have abdominal distension, obstipation, bilious and feculent vomiting and failure to pass meconium within the first 48 hours of life. Diagnosis is confirmed by rectal biopsy. A barium enema is not required but will show proximal dilation and distal narrowing. Treatment is surgery.

TRUE Hirschsprung disease is diagnosed during the neonatal period and patients have abdominal distension, bilious and feculent vomiting and failure to pass meconium within the first 48 hours of life.

Bottom Line: The video shows an abnormal finger-to-nose test, which in this scenario points to possible cerebellar ischemia secondary to sickle cell. The next best step in the management of this patient, given the answer choices, is an emergent CT scan of the brain.

TRUE The patient demonstrates dysmetria on finger-to-nose testing shown in the video. This is concerning for cerebellar pathology. Given the patient's history of sickle cell, he is at risk for ischemic stroke. Any patient presenting with stroke symptoms should have emergent CT scan of the brain to rule out other causes for the patient's symptoms, most importantly cerebral hemorrhage, especially if the patient is within the time window to receive TPA.

A patient who presents with respiratory distress following neck surgery must be immediately evaluated for a possible -----

The above patient is in respiratory distress secondary to a rapidly expanding hematoma. A patient with postoperative bleeding will present with neck swelling, neck pain, or signs of airway obstruction. An unrecognized or rapidly expanding hematoma can cause airway compromise and asphyxiation. Imaging studies provide little value. If airway obstruction is evident, the surgical site should be opened at the bedside to drain the blood and the patient transferred to the operating room for exploration of the wound. Note that bilateral recurrent nerve injury presents with respiratory distress immediately following extubation, whereas a hematoma needs time to accumulate and is more likely to present several hours following the surgery. The RLN innervates all the intrinsic muscles of the larynx except for the cricothyroid muscle, which is innervated by the superior laryngeal nerve. The superior laryngeal nerve consists of 2 branches. The internal branch provides sensation to the larynx, and the external branch provides motor innervation to the cricothyroid muscle. The cricothyroid muscle elongates the vocal folds, and injury results in poor vocal fold lengthening with resulting inability to form a high-pitched sound. Thyroid storm is an unusual complication of thyroid surgery, may result from manipulating the thyroid in a patient with hyperthyroidism, and can develop preoperatively, intraoperatively, or postoperatively. It presents as increased sympathetic output, with symptoms such as tachycardia, hyperthermia, nausea, tremor, or change in mental status.

The key component for differentiating nutritional rickets from X-linked hypophosphatemia is an elevated parathyroid hormone. Furthermore, nutritional rickets will present with an elevated alkaline phosphatase, elevated parathyroid hormone, and decreased phosphate.

Rupture of the distal biceps tendon may lead to loss of flexion and supination of the elbow with an absent C5 reflex. The biceps muscle is innervated by the musculocutaneous nerve.

The most likely diagnosis in this patient is a ruptured distal biceps tendon. The history and physical in this patient is consistent with a rupture of biceps tendon from its distal insertion onto the radial tuberosity. The sudden onset of pain is often associated with a popping noise. Physical exam may show decreased supination and flexion of the elbow. The C5 reflex is tested by tapping the distal biceps tendon with a reflex hammer and is often absent in patients with a biceps tendon rupture. The biceps muscle is innervated by the musculocutaneous nerve.

breach of duty

The physician should have realized the possible danger in allowing his patient to drive while using illicit drugs. The correct action would have been to call for an ambulance to have the patient brought to the emergency department.

Genetic screening should be offered to all patients. A first screen can be performed between 11 and 14 weeks gestation and a ------can be performed between 15 and 20 weeks gestation.

The quad screen is a test performed on maternal serum between 15 and 20 weeks gestation. Four serum levels are correlated with maternal age, race, gestational age and the presence or absence of insulin dependent diabetes to assess risk for neural tubes defects, trisomy 13, trisomy 18, and trisomy 21. The maternal markers evaluated are α-fetoprotein, estriol, β-hCG and inhibin-A. Inhibin-A is excluded in the triple-marker test. It is important to stress to the patient that this is a screening test. It assesses a patient's individual risk for the previously mentioned genetic abnormalities. This is not a diagnostic test.

The rule of 10's for pheochromocytoma: 10% are extra-adrenal, 10% are familial, 10% are bilateral, 10% are malignant, and 10% occur in children.

Bottom Line: The ulnar nerve is responsible for the cutaneous innervation of the dorsal aspect of the little finger. COMBANK Insight : Because of the anatomic arrangement of structures, the area around the elbow is the most common area for entrapment.

The ulnar nerve is responsible for the cutaneous innervation of the dorsal aspect of the little finger as well as innervation to the lumbricals and interossei. Because of the anatomic positioning of the ulnar nerve, it is subject to entrapment and injury by a wide variety of causes. It is the second most common entrapment neuropathy in the upper extremity. One of the most severe consequences is loss of intrinsic muscle function in the hand. Presenting symptoms of ulnar nerve entrapment can vary from mild transient paraesthesias in the ring and small fingers to clawing of these digits and severe intrinsic muscle atrophy. Treatment consists of ulnar decompression.

A mnemonic to remember common blastic or lytic cancers involving the bone is described as: "These Bony Lesions May Kill People"

These-thyroid-lytic Bony-breast-both (lytic or blastic) Lesions-Lung-lytic May-Multiple Myeloma-Lytic Kill-Kidney(renal cell)-Lytic People-Prostate-Blastic Although variations in reporting lytic or blastic lesions predominate with each type, often times breast and prostate are the most reported as blastic.

preeclampsia

This patient has signs and symptoms concerning for severe preeclampsia (blood pressure greater than 160/100 mmHg and dipstick with 5+ proteinuria as well as progressive renal failure) at 37 weeks. Preeclampsia is characterized by elevated blood pressure with proteinuria or evidence of end-organ injury in pregnant patients at >20 weeks gestation without pre-existing hypertension or renal disease. Patients at term and with severe preeclampsia should be promptly managed with hydralazine (or labetalol) to lower the blood pressure and magnesium sulfate to prevent progression to eclampsia. Once initial stabilization has been obtained, delivery should be carried out.Delivery is recommended for all preeclamptic patients when they reach 37 weeks gestation or earlier for those who develop features of severe disease or fetal compromise (e.g., fetal growth restriction). Delivery before these endpoints is not recommended to avoid complications associated with prematurity unless the patient is not able to be managed medically. Patients with severe preeclampsia and at term should first be stabilized with antihypertensive therapy and seizure prophylaxis. Delivery is performed afterward.

Bottom Line: The most common cause of hypercalcemia in an otherwise healthy, ambulatory patient is hyperparathyroidism.

This patient is presenting with an incidental finding of hypercalcemia. The most common cause of hypercalcemia in an otherwise healthy, ambulatory patient is hyperparathyroidism. The most common clinical presentation of primary hyperparathyroidism (PHPT) is asymptomatic hypercalcemia. The diagnosis is usually first suspected because of the incidental finding of an elevated serum calcium on biochemical screening tests.In addition, PHPT may be suspected in a patient with recurrent nephrolithiasis. The initial diagnostic work up generally includes repeating the serum calcium with albumin correction or obtaining an ionized calcium to confirm that hypercalcemia is actually present. Recall that calcium is bound to albumin and that the level of serum albumin can affect the laboratory interpretation of serum calcium. The lower the albumin, the lower the normal serum calcium. This correction can be avoided with a direct ionized calcium measurement.If hypercalcemia is confirmed, then a serum calcium should be redrawn with an intact PTH to evaluate the parathyroid response. If the calcium and PTH are both elevated then hyperparathyroidism is confirmed. If the PTH is normal or only minimally elevated, then a vitamin D should be measured and urinary calcium excretion can be evaluated. If the PTH is normal or low, then this is concerning for non-PTH mediated hypercalcemia, and vitamin D as well as parathyroid hormone-related peptide should be measured. There are a variety of causes of hyperthyroidism. Some of the causes that you may encounter are shown below:

Bottom Line: Normal radial head positioning is anterior with supination and posterior with pronation. Falling on an outstretched pronated hand will cause posterior radial head dysfunction and restriction in supination and anterior glide of the radial head.

This patient is suffering from a posterior radial head and restriction of supination, most frequently caused by falling on an outstretched hand. In normal movement, the radial head moves anterior with supination and posterior with pronation.

Bottom Line: PCOS presents with hirsutism, amenorrhea, obesity, and insulin resistance. An increased LH/FSH ratio is characteristic. COMBANK Insight : Medical management of PCOS is aimed at the treatment of metabolic derangements, anovulation, hirsutism, and menstrual irregularity.

This patient most likely has polycystic ovarian syndrome (PCOS) characterized by hirsutism, obesity, amenorrhea, and insulin resistance. The key laboratory findings are elevated estrogen and LH. The high estrogen can inhibit FSH secretion, thus leading to an increased LH/FSH ratio (because FSH is decreased and LH is increased). Elevated cortisol levels suggests Cushing syndrome, which may present in a similar way, but is less common. Clues for Cushing syndrome include central obesity, a moon face, purple striae, and hypertension. Hirsutism can occur with Cushing, but it is more closely associated with PCOS.

Perinuclear antineutrophil cytoplasmic antibody (p-ANCA), not c-ANCA, has been described in up to 80% of patients with PSC, as well as in 30% of their unaffected family members. P-ANCA in PSC appears to be unrelated to ulcerative colitis, as it may be seen in patients with PSC without ulcerative colitis. In addition, recent investigation has shown that antibodies to the baker's yeast Saccharomyces cerevisiae (ASCA) are found in up to 44% of patients with PSC irrespective of the presence of IBD, but its significance is yet to be determined.

This patient most likely has primary sclerosing cholangitis (PSC). Hypergammaglobulinemia is present in 30% of patients, and 50% have increased immunoglobulin M (IgM) levels. Changes in immunologic markers are not unusual. Serum immunoglobulin levels are frequently elevated, particularly IgG and IgM. Although serum IgG4 levels are usually within normal limits, approximately 9% of patients can present with elevated IgG4 (>140 mg/dL). These patients differ from those with normal serum IgG4 levels in that they have a lower frequency of associated irritable bowel disease (IBD).

Achilles tendonitis is a common condition in active young athletes, especially marathon runners. Heel pain and tenderness to palpation on the Achilles tendon are common. The ---------should be negative.

Thompson test The most likely diagnosis in this patient is Achilles tendonitis. Achilles tendonitis is a common overuse syndrome seen in active young athletes. This patient is currently training for a marathon, making Achilles tendonitis a likely diagnosis. Physical exam usually shows tenderness to palpation along the Achilles tendon down to its insertion onto the calcaneous. Pain with contraction of the gastrocnemius is a common physical exam finding. Achilles tendon rupture would result in a positive thompson test

------- presents with painless vaginal bleeding in the third trimester. A prior Cesarean section is a risk factor.

True

A clinical scenario describing a gallstone passing from the gall bladder to the common bile duct and causing obstructive symptoms which can lead to pancreatitis is choledocholithiasis.

True

A computed tomography (CT) scan of the pelvis is generally not recommended during pregnancy and is not indicated when ultrasound is an option. Even in the acute setting such as appendicitis, a magnetic resonance scan could be performed.

True

A levonorgestrel IUD is a good option for birth control for a patient who does not want to take a daily pill and has heavy menstrual bleeding. Levonorgesterel leads to a decrease in menstrual bleeding.

True

A right ventricular infarct is unique, in that treatment is different than other types of MIs. Avoid nitrates and give IV fluids to maintain perfusion through the failed right ventricle.

True

A somato-visceral reflex occurs when abnormal somatic stimuli enter the spinal cord and results in altered function of a visceral organ.

True

Abruptio placentae is predisposed by hypertension, cocaine abuse, and smoking.

True

Answer A: Corticosteroids can exacerbate pseudotumor cerebri.Answer B: Vitamin A can exacerbate pseudotumor cerebri.Answer C: Discontinuing oral contraceptive pills without discontinuing isotretinoin is not a good idea because isotretinoin is highly teratogenic. Tight prescription rules are in place to prevent pregnancy in patients on isotretinoin, one being that the patient must be on some form of contraceptive.Answer E: In any patient with papilledema, neuroimaging (either CT or MRI) of the brain must be done before a lumbar puncture to rule out a mass lesion. Doing a lumbar puncture on a patient with a mass lesion is high risk for herniation through the foramen magnum.

True

Answer E: Vulvar itching, along with signs of vulvar irritation such as erythema and excoriation of the vulvar skin, would make vulvovaginitis a more likely diagnosis.

True

Bottom Line: Patients with iron overload should be counseled against eating undercooked seafood to prevent exposure to Vibrio species due to their increased pathogenicity in the presence of excess serum iron.

True

Budd-Chiari syndrome is caused by thrombosis of the hepatic veins or inferior vena cava preventing blood from leaving the liver. Patients typically have an underlying hypercoagulable state and commonly present with sudden-onset abdominal pain, jaundice, and large-volume ascites.

True

Chart review studies require IRB approval but do not usually require informed consent from participants. True or false?

True

Children with attention deficit hyperactivity disorder (ADHD) often have other comorbidities, including Tourette syndrome, oppositional defiant disorder, and conduct disorder. Conduct disorder is a childhood disorder characterized by antisocial behavior including stealing, fighting, destroying property, and forced sexual activity. It is more common in children with ADHD.

True

Colorectal cancer is the third most common and third most fatal cancer in both males and females in the United States. Recent trends in the United States suggest a disproportionately higher incidence and death from colon cancer in African-Americans than in whites. Hispanic persons have the lowest incidence and mortality from colorectal cancer.

True

Focal nodular hyperplasia (FNH) is a tumor-like condition that is more common in women than men. It has an unknown cause, but it thought to be a reaction to injury. Gross findings of the mass include a poorly encapsulated nodule with a central depressed stellate scar that contains blood vessels. Its appearance on CT scan is described as a hypervascular mass containing arteriovenous connections. FNH is best observed, unless the mass grows large enough to cause pain. If it causes the patient significant discomfort, it can be removed surgically. FNH is not as common as cavernous hemangiomas. Furthermore, it is a tumor-like condition, not an actual tumor.

True

Hepatic adenomas are benign tumors of hepatocytes. They occur more commonly in women than in men, and are associated with OCP and anabolic steroid use. While common, they are not as common as cavernous hemangiomas.

True

Hermansky-Pudlak presents with amblyopia and oculocutaneous albinism. These patients do not have the silver hair seen in Chediak-Higashi or the infectious complications, but they may have pulmonary fibrosis.

True

IV pyelogram would be beneficial if nephrolithiasis was suspected, but is rarely done and would not be of diagnostic benefit in this case given the normal urinalysis. The IV pyelogram is generally not favorable due to the need for IV contrast, risk of contrast nephropathy, and generally poorer quality of images as compared to ultrasonography.

True

If a patient has an anaphylactic reaction from a blood transfusion, IgA deficiency should be considered. The transfusion should be stopped and epinephrine given.

True

In RTA type 2, the defect is located proximally and is strongly associated with Fanconi syndrome. It is caused by a failure of the proximal tubules to reabsorb bicarbonate (hence causing acidosis), as well as other solutes like glucose, amino acids, and phosphate. Causes of RTA type 2 include multiple myeloma, Fanconi syndrome, and certain drugs. In this patient with Sjögren's syndrome and kidney stones, it is more likely to be RTA type 1.

True

Increased deep tendon reflexes, or hyperreflexia, indicate an upper motor neuron lesion. Some examples would include spinal cord injury, cerebral palsy, multiple sclerosis, or stroke.

True

Legg-Calvé-Perthes disease (LCPD) is avascular necrosis of the proximal femoral head resulting from compromise of the tenuous blood supply to this area. LCPD usually occurs in children age 4 to 10 years. The disease has an insidious onset and may occur after an injury to the hip. In the vast majority of instances, the disorder is unilateral. The earliest sign of LCPD is an intermittent limp (abductor lurch), especially after exertion, along with mild or intermittent pain in the anterior part of the thigh. LCPD is the most common cause of a limp in the 4- to 10-year-old age group, and the classic presentation has been described as a painless limp. The patient may present with limited range of motion of the affected extremity

True

Lymphatic malformations, which include lymphangioma and cystic hygroma, represent areas of localized abnormal lymphatic development. Approximately half of all lymphatic malformations are diagnosed at birth, and over 90% are diagnosed by age 2 years, making this an unlikely diagnosis. Most lymphatic malformations present as slow-growing cystic cervical masses.

True

Neonatal respiratory distress syndrome presents with tachypnea, nasal flaring, intercostal retractions, cyanosis, and grunting within the first hour of delivery. Evidence shows that antenatal corticosteroid therapy reduces NRDS when given between 24-34 weeks gestation for high-risk patients.

True

Otosclerosis has autosomal dominant inheritance.

True

Paget's disease of the breast is a malignancy of the epidermal layer of the nipple and is responsible for 1-3% of all cancers of the breast. Eczematous changes of the nipple, along with distortion, scaling, crusting, and plaque formation are classic presenting features of the disease.

True

Petechiae are the most common skin manifestation of thrombocytopenia.

True

The steeple sign is a sign on a frontal radiograph of tracheal narrowing and suggestive of the diagnosis of croup.

True

Leukocoria in children prior to the age of 5 years should be regarded as retinoblastoma until proven otherwise. In children with leukocoria and strabismus, the suspicion should be even higher. Over 50% of new cases of retinoblastoma are discovered because of an isolated finding of leukocoria.

True Retinoblastoma is the most common primary ocular malignancy of childhood. The incidence is about 11 cases per million children younger than 5 years old. Over 50% of patients present with leukocoria. The second most common finding is strabismus. Glaucoma and other secondary changes may also be noted in later disease states. The treatment is determined by the size and location of the tumor. Enucleation with radiation and cryotherapy are mainstays of treatment. Chemotherapy is also used.

Bottom Line: Bone tumors with distant metastasis are classified as stage III.COMBANK Insight : The Enneking system for bone tumors is not high-yield. However, knowing that Stage III represents metastasis may be useful in your examination.

Under the Enneking system, malignant tumors are classified into stages I-III, with further subdivisions into A and B. Grade 1 and grade 2 tumors are stage I and stage II, respectively. T1 and T2 tumors are stage A and stage B, respectively. Tumors with distant metastasis are stage III. In the Enneking system, bone tumors are graded as follows (not high-yield):G0 - Benign lesionG1 - Low-grade malignant lesionG2 - High-grade malignant lesionT0 - A benign tumor that is confined within a true capsule and the lesion's anatomic compartment of origin (i.e., a benign intracapsular, intracompartmental lesion) T1- An aggressive benign or malignant tumor that is still confined within its anatomic compartment (i.e., an intracompartmental lesion) T2 - A lesion that has spread beyond its anatomic compartment of origin (i.e., an extracompartmental lesion)M0 - No regional or distant metastasisM1 - Regional or distant metastasis

---- is a common complication following greater saphenous vein harvesting due to decreased venous return in the affected extremity.

Unilateral lower-extremity edema

COMBANK Insight : The treatment of patients with septic shock consists of 2 major goals:1. IV fluid resuscitation with use of pressors if needed 2. Early administration of appropriate antibiotics By achieving these 2 goals, you are trying to ultimately improve organ perfusion and help the body get through the infection without going into organ failure.

Vasodilation is noted early on in septic shock, secondary to bacterial toxins and the immune response, and contributes to hypotension. This requires aggressive fluid resuscitation along with early antibiotic administration.

-------- is a term used to describe when someone is liable for the negligent actions of another person, even though the first person had no direct involvement with the injury. An example of this would be an attending physician being held liable for the actions of the resident physician.

Vicarious liability

-------- refers to the doctrine stating that a person who knowingly places him- or herself at risk for danger cannot sue for any resulting injuries that may occur.

Volenti non fit injuria

Risk factors for Vulvovaginal Candidiasis

Vulvovaginal candidiasis is associated with recent antibiotic use, pregnancy, and uncontrolled diabetes and presents with a thick, white discharge, pruritis, dyspareunia, and sometimes dysuria. Candida albicans typically presents with thick clumpy white cottage cheese or white curdy like discharge. KOH wet mount will reveal pseudohyphae and the pH will be 3.5 - 4.5.

Diseases with inheritance include: fragile X, Duchenne muscular dystrophy, hemophilia A and B, Fabry disease, G6PD deficiency, Hunter syndrome, and Wiskott-Aldrich syndrome.

X-linked recessive inheritance

x-ray findings of small bowel obstruction

X-ray findings for small bowel obstruction (SBO) include air-fluid levels, dilated loops of small bowel, and no gas in the colon, and SBO is commonly caused by adhesions, hernias, and malignancy.

Venlafaxine is the treatment of choice for patients with hot flashes who smoke. Although the treatment of choice is estrogen-containing hormone replacement therapy, this cannot be given as this is a contraindication in patients who smoke. Venlafaxine can be used to treat hot flashes but does not have any effect on the vulvovaginal atrophy and dyspareunia that are associated with menopause. Venlafaxine is -----

a selective norepinephrine reuptake inhibitor.

The usefulness of fomepizole for the treatment of disulfuram toxicity is theoretical, and it is not widely used clinically. However, it is considered an antidote in medical literature and is thus fair game for the COMLEX. Fomepizole blocks ethanol metabolism to acetaldehyde, decreasing the accumulation of ----

acetaldehyde.

House fires are a common cause of cyanide poisoning. Cyanide is produced from the combustion of certain materials such as furniture during the course of a house fire. Cyanide may present with coma, seizures, heart dysfunction, metabolic acidosis, and breath that smells like bitter almonds. Metabolic acidosis occurs because cytochrome oxidase enzymes in the electron transport chain are inhibited, which leads to a shift from aerobic to anaerobic metabolism, in turn producing high levels of lactic acid. Cyanide poisoning may be treated with ----- and -------

amyl nitrite and thiosulfate.

The ------ is the most common injured knee ligament and presents classically with a "pop."

anterior cruciate ligament (ACL)

Answer I: Asking about influenza vaccinations does not assist in making a diagnosis for chest pain in this scenario.

asking about influenza vaccination does nothing in helping with chest pain While asking about allergies is important (especially when considering what medications patients cannot take), in this scenario, allergies would not assist you in obtaining an accurate DIAGNOSIS. It would help in determining treatment if the patient endorsed allergies to certain medications.

The rash of ------is chronic in most cases and is a highly pruritic, eczematous dermatitis which is caused by an IgE mediated type-1 hypersensitivity reaction.

atopic dermatitis

Vicarious Liability

attending physician being responsible for any negligence committed by any resident physician under the attending physician's supervision.

A negative KOH preparation effectively rules out fungal causes (tinea) for COMLEX exam purposes. To differentiate tinea corporis from eczema, tinea is more likely to have areas of central clearing within a round, scaly plaque. Management of tinea corporis involves the use of topical antifungals, particularly ----

azoles.

By agreeing to perform surgery on the patient, the surgeon has a duty to provide care to the patient. An example of a -------would be abandonment of the patient, which does not apply in this case, as the surgeon is performing surgery on the patient.

breach of duty

Hyperparathyroidism is associated with -----stones.

calcium

Patients with ulcerative colitis are at an increased risk of primary sclerosing cholangitis (PSC). Patient's with PSC are at higher risk of developing -----

cholangiocarcinoma.

Although invasive, ------- remains the most expeditious and definitive testing available for early detection of trisomy 21. It should be offered to all patients who are positive on first trimester screening tests.

chorionic villus sampling

A ----wound is one in which no inflammation or infection is encountered and no hollow viscous is entered.

clean wound

A ------ wound is one in which a hollow viscous is entered under controlled purposeful effort with no gross contamination of the surgical field.

clean-contaminated

Findings consistent of preeclampsia before 20 weeks, uterine enlargement, disproportional fundal height, and "snowstorm pattern" on ultrasound with no gestational sac all point to the diagnosis of -------

complete molar pregnancy. Dilatation and curettage (D&C) is necessary to evacuate the uterus following diagnosis of molar pregnancy. The presenting signs/symptoms are consistent with the diagnosis of molar pregnancy. It is important to remember that hydatidiform moles are capable of developing into a malignant disease called gestational trophoblastic neoplasm. As such, evacuation of the uterus by dilatation and curettage (D+C) or dilation and evacuation (D+E) is always necessary following this diagnosis.Answer A: Prostaglandin administration is not recommended because of the increased risk of bleeding and malignant sequelae that may occur if the pregnancy isn't terminated.Answer C: Induction of labor with oxytocin is not recommended because of the increased risk of bleeding and malignant sequelae that may occur if the pregnancy isn't terminated and completely evacuated. Questions dealing with gynecologic surgeries are very common and show up frequently on COMLEX exams. Look for these questions to appear in matching format or as 2nd or 3rd steps in multi-level cases.

Conjunctival melanomas usually arise from acquired melanosis of the conjunctiva, with the remainder arising de novo or from ??. The aggressive nature of these neoplasms is dependent on the histological composition, with spread via lymphatic channels or direct invasion.

conjunctival nevi.

Wegener's granulomatosis is a necrotizing vasculitis that affects the lungs, upper respiratory system and kidneys which leads to nephritic syndrome. Patients present with saddle nose, rhinitis, hemoptysis and other upper and lower respiratory symptoms. A positive c-ANCA is also another typical finding. Chest X-ray may show cavitary nodules. Treatment is with-------

cyclophosphamide.

The usefulness of fomepizole for the treatment of ----toxicity is theoretical, and it is not widely used clinically. However, it is considered an antidote in medical literature and is thus fair game for the COMLEX. Fomepizole blocks ethanol metabolism to acetaldehyde, decreasing the accumulation of acetaldehyde. Fomepizole also acts as a competitive inhibitor to methanol, thus delaying methanol metabolism until the methanol is eliminated. Ethanol works similarly and is a less expensive and more readily available alternative to fomepizole.

disulfuram

After giving methotrexate to treat an -------- patients must be carefully followed. The day the methotrexate is given is considered day 1. The β-human chorionic gonadotropin (β-hCG) will be checked again on day number 4. It is typical for the β-hCG to increase during the first couple of days. If it rises during this point, nothing needs to be done. However, between day number 4 and day number 7 the β-hCG must decrease by at least 15%. If the β-hCG decreases by at least this much, then the β-hCG will be checked every week until the level reaches 0. If the β-hCG does not decrease by 15%, then another dose of methotrexate is warranted if the patient remains stable and there are no signs of rupture.

ectopic pregnancy,

Any postmenopausal woman who presents with vaginal bleeding must have an ----- to exclude malignancy.

endometrial biopsy

This is the most common gram-positive organism found in infected bile, but it is not the most common organism overall.

enterococcus

Fomepizole and also ----may be used as antidotes for methanol toxicity.

ethanol

Diagnosis of HD is best made with--------because fine-needle biopsy is usually nondiagnostic.

excisional lymph node biopsy,

The mechanism of cromolyn sodium is to prevent airway inflammation by inhibiting mast cell degranulation. It is only effective for prophylaxis and is not effective during an acute asthma attack. It is especially useful for -------

exercise-induced bronchospasm.

Restricted forearm supination and tenderness over the radial head indicates a posterior radial head.right posterior radial head. During pronation the radial head moves posteriorly, while during supination the radial head moves anteriorly. In this case, the patient has restriction from active and passive supination of the forearm, indicating a restricted anterior glide of the radial head. The etiology of this somatic dysfunction is often an individual --------

falling forward on a pronated forearm.

Side effects of ------include myelosuppression, mucositis, dermatitis, diarrhea, and cardiac toxicity. There are no side effects of pulmonary fibrosis.

fluorouracil

Amenorrhea in Turner syndrome is caused by ovarian failure and, thus, is characterized by elevated ----

follicle-stimulating hormone levels. Patients with Turner syndrome are in low-estrogen states because of ovarian (gonadal) dysgenesis. Labs will show elevated follicle-stimulating hormone (FSH) indicating nonfunctional ovaries.

t(14;18) bcl-2 is associated with ----

follicular lymphoma.

Escherichia coli 0157:H7 is a highly virulent strain of E coli that causes hemorrhagic diarrhea and is typically associated with consumption of -----

hamburger meat. Hemolytic uremic syndrome (HUS) is a clinical syndrome characterized by progressive renal failure and a nonimmune, Coombs-negative hemolytic anemia and thrombocytopenia. There is an association between Escherichia coli 0157:H7 and the development of HUS, and it is most common in children older than age 10 years. Shigella, viral infections, systemic lupus erythematosus, antiphospholipid antibody syndrome, and streptococcal infection are also associated with the development of HUS. Clinically, HUS causes anemia, thrombocytopenia, intrarenal acute renal failure, and hyperbilirubinemia secondary to hemolysis. Red blood cells are commonly seen in the urine, along with a mild proteinuria. This is differentiated from the pentad of thrombotic thrombocytopenic purpura, which is a medical emergency characterized by the HUS triad plus fever and/or fluctuating neurologic signs.

The most common predisposing factor to dissection development is -------- Other predisposing factors include smoking, hypercholesterolemia, older age, male gender, Ehlers-Danlos syndrome, Marfan's syndrome, and family history.

hypertension.

Rupture of the flexor digitorum profundus tendon causes -------, where an individual is unable to actively flex at the DIP joint. Etiology is usually traumatic in nature, and it does not affect the MCP or PIP joints.

jersey finger,

Scheuermann's disease, also known as------ is a deformity of the thoracic or thoracolumbar spine in children. Lateral radiographs will show wedge-shaped vertebral bodies, rigid kyphosis, and a narrowing of intervertebral disk spaces.

juvenile kyphosis,

Limited or mild plaque psoriasis can be managed well with topical corticosteroids, moisturizers/emollients, topical vitamin D analogs (eg, calcipotriene or calcitriol), tar, and topical retinoids (tazarotene). However, our patient has tried conservative management, and his disease is still worsening. Because his psoriasis plaques cover greater than 30% of his body, he has moderate to severe disease and needs more aggressive management options LIKE?.

like the UVB light or PUVA

Antibiotics of choice for common infections such as pneumonia, otitis media, sinusitis, urethritis, and cervicitis will get you several easy points on test day. It is also good to know the alternatives for patients with allergies to medications. Charts can be very helpful to keep this information organized and easily accessible.

make sure to review this

t(11;14) bcl-1 is associated with ----

mantle cell lymphoma.

The ------ is responsible for the cutaneous innervation of the palmar aspect of the thumb. Injury to this nerve anywhere along its course in the upper extremity can result in a deficit of this sensation; however, carpal tunnel syndrome is the most common focal peripheral neuropathy. Carpal tunnel syndrome is caused by entrapment of the median nerve at the wrist as it traverses through the carpal tunnel. Most often, the symptoms are in the thumb, index, and middle fingers.

median nerve

The first and second lumbricals are innervated by the -----

median nerve.

A spike and dome appearance occurs due to granular deposits of IgG and C3 at the basement membrane and is associated with ------- This type of nephrotic syndrome is associated with hepatitis B virus, syphilis, malaria, and exposure to gold salts. It is the most common nephropathy in Caucasian adults.

membranous nephropathy.

Bottom Line: Patients given -----must have β-hCG levels followed. From day 4 until day 7, the level must drop by 15%. If it does not, another dose of ---- is warranted.

methotrexate

Diseases with --------include: progressive external ophthalmoplegia and myoclonus epilepsy.

mitochondrial inheritance

Digoxin can be used as an adjunct in the treatment of atrial fibrillation but is less effective for rate control than calcium channel blockers or beta-blockers. Digoxin slows the ventricular rate during atrial fibrillation primarily by vagotonic inhibition of AV nodal conduction. In patients with heart failure due to systolic dysfunction and atrial fibrillation, digoxin has two potential benefits, which are a reduction in the ventricular rate and improvement in contractility. However, since digoxin is less effective in rate control than beta-blockers and calcium channel blockers and has --------it should not be used as a first-line treatment.

no ability to terminate atrial fibrillation,

Angiosarcoma of the liver most commonly arises in older males. It is a high-grade malignancy, and initial signs and symptoms are nonspecific; therefore, key to the presentation of this tumor is a history of exposure to arsenic, vinyl chloride, anabolic steroids, radiation, or thorium.

okay

Acute stress disorder develops within -----of being exposed to a severe traumatic event that involves death or serious injury. The symptoms are similar to post-traumatic stress disorder which includes nightmares and flashbacks of the event.

one-month

The Joint Commission -----

operates accreditation programs to subscriber hospitals and other health care organizations. A hospital that meets Joint Commission accreditation is deemed to meet the Medicare Conditions of Participation (which is a requirement for Medicare).

Hyperpigmentation of the skin on the anterior legs is consistent with ------a finding exclusive to patients suffering from Graves disease.

pretibial myxedema In elderly individuals, fewer symptoms are apparent to the patient. Clues may include unexplained weight loss, hyperhidrosis, or rapid heartbeat. Infiltrative ophthalmopathy (proptosis) and infiltrative dermopathy (pretibial myxedema) are characteristic of Graves disease but not other causes of hyperthyroidism.

Meta-analyses make it possible to look at events that were too rare in the original studies to show a statistically significant difference. This is a potential strength of pooling data from multiple studies.

rare event effect

The dorsal scapular nerve does not provide innervation to the shoulder. It innervates the -------

rhomboids and levator scapulae.

The ------ occurs when small studies have different effects than large ones, either due to lower methodological quality, publication bias, or other factors. This is another potential source of bias in a meta-analysis, but unlike publication bias, it will not always bias in one specific direction.

small-study effect

Patients with tricyclic antidepressant toxicity tend to present with mydriasis, hypo-/hypertension, tachycardia, urinary retention, decreased bowel sounds, flushed/dry skin, confusion/agitation/hallucinations, and hyperthermia (Hot as Hades, Mad as a Hatter, Blind as a Bat, Dry as a Bone, and Red as a Beet). First-line treatment is administration of ------along with charcoal and/or gastric lavage.

sodium bicarbonate

The danger of a paraesophageal hernia is that the stomach can get ---

strangulated.

The test described in the question is the empty can or Jobe's test and is considered the gold standard test for supraspinatus function. The position described in the stem makes the supraspinatus the primary muscle opposing the downward force of the examiner. If there is only pain with this test and no weakness, that is indicative of tendinopathy rather than tear.Another test for the supraspinatus would be the drop arm test in which patients raise their arms over their head in full abduction and then lower them smoothly to their sides. If they cannot adduct their affected arm smoothly (usually having it "drop" instead), then the test is positive. This is because the first 20 to 30 degrees of abduction are usually handled by the supraspinatus tendon and a tear of this muscle results in the inability to smoothly lower the arm.

suprascapular nerve innervates it

The most effective treatment is emergent bile duct decompression. This may be accomplished via percutaneous drainage, open surgery, or ERCP-assisted sphincterectomy.

The goal in -------- involves interventions to prevent further deterioration or complications of a disease process.

tertiary prevention

Bottom Line: Consider the diagnosis of ------- in an intravenous drug user with focal or diffuse muscle contractions and lockjaw.

tetanus Tetanus is caused by the spores of Clostridium tetani, which produce the neurotoxins tetanospasmin and tetanolysin. Tetanospasmin acts at the myoneural junction, resulting in the inability of the neurons to be inhibited and causing a chronic contractile state at the motor end place. Quinine, the diluting agent in heroin, is a supportive growth medium for C. tetani. Tetanus presents with trismus (lockjaw), glottal spasm, and convulsive spasms. People at risk of developing tetanus are the elderly (due to inadequate immunization), intravenous drug users, and patients with ulcers. Management of tetanus involves the use of benzodiazepines to control muscle spasms, neuromuscular blockade if needing to control the airway, and metronidazole as the antibiotic of choice. Tetanus immune globulin and or tetanus toxoid may be indicated in patients presenting with wounds at risk of infection depending on previous vaccination.

Follicular carcinoma represents about 17% of thyroid cancers. Papillary and follicular types have some similarities but are differentiated by a few distinct factors. Both types are found in thyroid hormone-producing cells and have a good prognosis. Survival rates are 90% after 10 years, which is similar to papillary type. Because the follicular type usually spreads via --------metastases are usually found in the lung or bone.

the bloodstream,

Adjustment disorder develops within ----- of an identifiable stressor. The symptoms are in excess of what would be expected from the stressor. This patient has started college and was separated from her family for the first time (stressors) and as a result is experiencing symptoms of depression and anxiety that are significantly impairing her function.

three months

The intent of the Healthcare Integrity and Protection Data Bank (HIPDB) ------

to combat fraud and abuse in health insurance and health care delivery.

Clinical presentation of serotonin syndrome

tremor, fever, diarrhea, restlessness, and diaphoresis.

Acute pericarditis has multiple different etiologies, including postviral, postsurgical, and autoimmune. The EKG findings is ST elevation in all 12 leads. Treatment consists of anti-inflammatory medication.

true

Amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig disease, is a progressive, fatal, neurodegenerative disorder caused by the degeneration of motor neurons. The corticospinal tract and ventral horn of the spinal cord are affected, resulting in spastic and flaccid paralysis. Nearly 75% of patients experience "limb-onset" ALS, which typically presents with weakness of one of the legs, which is noted during ambulation. Look for someone who complains of tripping or stumbling while walking. Patients may also first see the effects of the disease in their hands or arms, causing difficulty with simple tasks requiring manual dexterity including buttoning a shirt or turning a key in a lock. The hallmark neurologic findings in ALS are mixed upper motor and lower motor neuron signs. In this case, the patient has fasciculations (lower motor neuron sign) and hyperreflexia (upper motor neuron sign).

true

Bottom Line: Rapid onset of new urinary retention with loss of lower limb sensation/reflexes suggests cauda equina syndrome.

true

Bottom Line: Subacromial bursitis commonly presents with shoulder pain and can be elicited with Neer's impingement test.

true

Brain death is defined as irreversible loss of brain and brainstem function and is determined by multiple precursors and a thorough physical exam. Imaging is not needed routinely, and although state laws may vary, the AAN has outlined clear guidelines for defining brain death.

true

Displacement is described as avoided feelings that are transferred to another person or object.

true

In older individuals with an atrial septal defect, there is a fixed splitting of the second heart sound (or S2). There is a fixed splitting of the second heart sound because the extra blood return during inspiration gets equalized between the left and right atrium due to the communication that exists between the atria. If the atrial septal defect does not cause symptoms, treatment is unlikely.

true

Kussmaul respirations are commonly seen in patients suffering from diabetic ketoacidosis or any cause of metabolic acidosis and are characterized by very deep breaths at a constant rate. The patient's speech pattern may be choppy secondary to the deep pattern.

true

Marfan syndrome is associated with mitral valve prolapse.

true

Neurofibromatosis type 1 diagnostic criteria include multiple café-au lait macules, Crowe sign (axillary freckling), lisch nodules, sphenoid dysplasia, neurofibromas, optic glioma, and first-degree relative with the condition.

true

Patients with left-sided heart failure often develop transudative pleural effusions secondary to increased hydrostatic pressure.

true

Remember to warn your patients not to drink alcohol while on metronidazole as it can cause a disulfiram-like reaction.

true

Selenium is a trace mineral found in its organic form in animal proteins, such as seleno-cysteine and seleno-methionine. Recently, it has gained notable attention for its role as an antioxidant. Deficiency is classically associated with skeletal muscle dysfunction, an impaired immune system, white nail beds, and most notably cardiomyopathy.

true

The initial manifestation of magnesium toxicity is a decrease in deep tendon reflexes.

true

The levator palpebrae superioris is a muscle that controls the movement of the upper eyelid. Damage to this muscle can result in a ptosis and defective elevation of the affected eyelid.

true

The most likely diagnosis in this patient is lateral epicondylitis. Lateral epicondylitis is a common condition affecting laborers and tennis players and is commonly called tennis elbow. It presents with lateral elbow pain that is exacerbated resisted extension of the wrist. Patients will commonly complain of exacerbation with lifting activities with the hand in full pronation. Conservative treatment is the mainstay and consists of rest, ice, compression elbow straps, stretching, and physical therapy. When conservative treatments fail, corticosteroid injections are the next most appropriate step in management. If conservative treatment and corticosteroid injections fail to resolve the inflammation, surgical debridement is indicated.

true

The most likely diagnosis is von Willebrand's disease. VWD is a condition in which patients have deficient or defective vWF with low levels of factor VIII and is inherited in an autosomal dominant fashion. Bleeding episodes can be treated with DDAVP and preventative measures such as avoiding aspirin should also be utilized. DDAVP is a form of vasopressin that increases the release of stored vWF and factor VIII from platelets.

true

The patient is suffering from a pheochromocytoma and should be screened with 24-hour urinary catecholamine metabolite levels. The diagnosis of pheochromocytoma is typically confirmed by measurements of urinary and plasma fractionated metanephrines and catecholamines. Please refer to the evaluation algorithm for pheochromocytoma listed in the references.

true

The presence of antibodies to the surface antigen, but not the core antigen, is the hallmark of a successful vaccination.

true

The temporal lobe is responsible for auditory reception, expressed behavior, receptive speech, and memory retrieval. Strokes in this area are often associated with aphasia.

true

This patient is demonstrating signs and symptoms of acute interstitial nephritis (AIN) secondary to treatment with ciprofloxacin. Drug-induced acute interstitial nephritis can be caused by several medications, including penicillins, cephalosporins, rifampin, sulfa drugs, quinolones, NSAIDs, diuretics, allopurinol, and phenytoin. Treatment of AIN requires cessation of the offending drug and observation to see if symptoms resolve. If symptoms do not improve, the next step in management would be to consider a trial of steroids. The definitive test for diagnosis of AIN is kidney biopsy, but this is only utilized when clinical diagnosis is difficult because of its invasive nature.

true

This patient most likely has the diagnosis of placenta previa due to painless vaginal bleeding in the second trimester. Due to acute blood loss, the patient is suffering from hypovolemic shock. The loss of blood results in intravascular volume depletion, which affects cardiac output (CO), pulmonary capillary wedge pressure (PCWP), and peripheral vascular resistance (PVR). These effects occur due to decreased preload.Hypovolemic shock: Decreased CO, Decreased PCWP, Increased PVRCardiogenic shock: Decreased CO, Increased PCWP, Increased PVRSeptic shock: Increased CO, Decreased PCWP, Decreased PVR

true

Thoracic inlet is treated first when the lymphatic system is the primary target. First start with the thoracic inlet, and then the diaphragms, including thoracolumbar, pelvic, and cranial. The next steps in treatment are lymphatic pumps to mobilize fluid and then local lymphatic treatments. The last step in the treatment of lymphatics typically involves an abdominal and/or pedal pump.

true

Up to one-third of panic disorder cases are associated with depression; therefore, it is important to screen and treat patients for this comorbid condition.

true

Urinary tract infections (UTIs) are the most common bacterial infections during pregnancy and are most commonly caused by the organism Escherichia coli, which accounts for over 80% of infections. E. coli is the most common cause of UTIs in both pregnant and non-pregnant females and should be suspected unless other information is given to suggest otherwise, such as gram-stain results (E. Coli is a gram negative rod). Recall that E. Coli is an enteric bacteria and commonly infects the urinary tract in women due to the close proximity of the rectum to the vagina.

true

Vertical strain occurs when the sphenoid deviates superior or inferior relative to the occiput.

true

While depot medroxyprogesterone acetate can help to decrease bleeding, this patient is non-adherent and may not be trusted to come to the office every 3 months. Depot medroxyprogesterone acetate can be injected either intramuscularly or subcutaneous.It is a good choice for women who: Want a highly effective reversible contraceptive that does not require daily medication Cannot have or do not want an estrogen-containing contraceptive Want to eliminate regular menses Desire a reduction in endometriosis related pelvic pain Need a more private method of contraception Have physical or intellectual disabilities

true

Bottom Line: Bacterial vaginosis is treated with metronidazole or clindamycin. An adverse side effect of metronidazole is a disulfiram-like reaction.

true There are four main treatments of Bacterial vaginosis. They are oral and intravaginal metronidazole and oral and intravaginal clindamycin. Patients are given metronidazole in a single oral dose of 2 grams. These treatments have equivalent rates of cure. Metronidazole has a well-known adverse effect when it is consumed with alcohol. Patients experience a disulfiram like reaction where they experience nausea, vomiting, tachycardia, and flushing of skin.

The patient shows signs of shock with inadequate organ perfusion (confusion) and hypotension. Shock may be due to a number of etiologies. Abnormal vital signs must first be addressed, including treatment of this patient's hypotension. The patient must be resuscitated before further investigation can take place. Given the most likely diagnosis of acute pancreatitis on admission, the patient is likely intravascularly depleted secondary to third spacing, requiring aggressive fluid resuscitation. Acute pancreatitis is associated with increased microvascular permeability, leading to large volume losses of intravascular fluid into the tissues, thereby decreasing perfusion of the lungs, kidneys, and other organs. Fluid resuscitation is required to avoid shock, acute respiratory distress syndrome, and acute renal failure. This patient is hypotensive, tachycardic, hemoconcentrated (elevated BUN, creatinine and hematocrit), and has altered mental status. Augmenting circulation with a 1,000 - 2,000 mL fluid bolus is critical. Whole blood, dextran, or packed red blood cells may be used if the patient is anemic. Add vasoactive drugs (Incorrect Answer D) after intravascular volume is optimized. Insert foley catheter to monitor urine output, which should be greater than 0.5 mL/kg/hr. Assess mental status frequently, and consideration of an ICU consultation may be needed.

true Bottom Line: Acute pancreatitis is associated with large volume losses of intravascular fluid into the tissues, thereby decreasing perfusion of the lungs, kidneys, and other organs, and may lead to hypovolemic shock. The treatment of hypovolemic shock is aggressive fluid replacement with crystalloid solutions such as normal saline or lactated ringers. Whole blood or packed red blood cells can be used if the patient is anemic.COMBANK Insight : Resuscitation and addressing grossly abnormal vital signs take precedence over a more detailed investigation of the etiology of the patient's condition.

Other justifications for use of ARBs in patients previously diagnosed with ACEI related angioedema include: congestive heart failure therapy, proteinuric nephropathy states, high-risk cardiovascular patients, resistant hypertension responsive only to interruption of the renin-angiotensin axis, and/or multiple medication sensitivities requiring therapy with a medication class devoid of side effects.

true Bottom Line: The Beck Depression Inventory is used for patients exhibiting signs of major depression, like this patient.COMBANK Insight : The COMLEX will not likely ask about the details of psychiatric rating scales, but it will ask when it is appropriate to use them. The benefit of these rating scales is that their name usually involves the aspect they are testing, and the COMLEX will spell out the entire name instead of using the acronym (unless the acronym defines the rating scale name, as in the CAGE Questionnaire). This patient is experiencing signs of major depression and may be outside the normal bereavement window (6-12 months). The Beck Depression Inventory (with 21 multiple-choice questions) is one of the most widely used instruments for measuring the severity of depression.

Bladder diverticulum are outpouchings of tissue caused by mucosal herniation through the bladder wall. They may be solitary or multiple in nature and can vary considerably in size. Voiding cystourethrography (VCUG) is the single best imaging modality for the detection of bladder diverticula.Clinically, the problem with bladder diverticula is that they poorly empty during micturition which results in multiple lower urinary tract symptoms as well as recurrent urinary tract infections. They can be congenital or acquired. They are more common in men. Treatment is generally surgical.

true Bottom Line: Voiding cystourethrography (VCUG) is the most efficient and reliable method of detection for bladder diverticula.

This patient is presenting with what is commonly called a massive pulmonary embolus. To qualify as a massive PE there must be hypotension. Hypotension is defined as a blood pressure < 90/60 or blood pressure that requires vasopressors or inotropic support. In the setting of PE, the hypotension should not be easily explained by other causes such as sepsis, arrhythmia, left ventricular dysfunction from acute myocardial ischemia or infarction, or hypovolemia. Although hemodynamically unstable PE is often caused by large clot burden such as a saddle embolus, it can sometimes be due to small PEs in patients with an underlying cardiopulmonary disease. Thus, the term "massive" PE does not necessarily describe the size of the PE as much as its hemodynamic effect.Patients presenting with PE and signs of right heart strain should go for echocardiography. This subset of patients would include those with both massive and submassive pulmonary emboli. Massive PE is defined by circulatory collapse and shock, while submassive is defined by right heart strain alone. Tests that can help prognosticate pulmonary emboli include the troponin I measurement and the brain natriuretic peptide. Elevations of either of those markers in the setting of PE is concerning for heart strain and some institutions now perform thrombolysis for a subset of patients with submassive PEs. Not all patients with small, subsegmental PEs will require echocardiography, so the choice should be individualized based on concern for heart strain.Signs of right heart strain include a RV: LV ratio >0.9 on echocardiography, BNP >90, and troponin >.04. Other signs of right heart strain as listed before include a new RBBB and S1Q3T3 pattern on EKG. The treatment of massive PE is thrombolysis. The treatment of submassive PE is generally systemic anticoagulation without thrombolysis, though this is controversial and thrombolysis in submassive PE will not be tested.Bottom Line: While you may not get a question on the classification of PE, it is important to know them. PE can either be submassive or massive depending on the hemodynamic stability and presence of right heart strain.COMBANK Insight : PE is a commonly tested subject on the COMLEX. Know its presentation, treatment, and diagnosis.

true Bottom Line: When assessing patients for outpatient anticoagulant therapy you must assess the risks vs benefit. In this case, our patient has a high risk for recurrence given her risk factors (age, bed ridden, recent surgery) and would benefit from outpatient therapy. She does have a risk for bleeding given her fall history, however, that risk is less than generally believed; however, it would be appropriate to choose an anticoagulant with less bleeding risk such as a factor Xa inhibitor or direct thrombin inhibitor. As she ages, the risks and benefits of anticoagulation will need to be reassessed by her primary care physician and adjusted as needed.

Bottom Line: It is crucial to first locate the placenta via ultrasound when a women presents with 3rd trimester bleeding.COMBANK Insight : You must be able to differentiate placenta previa from placental abruption. Previa presents with painless bleeding while abruption presents with painful bleeding.

true Delivery by Cesarean section is the method of choice to deliver a previa. In the case above, diagnosis must first be established with an ultrasound. This patient is presenting with third trimester bleeding, which is a common and highly tested obstetrical problem. Painless and profuse bleeding is usually consistent with placenta previa although other causes should not be discounted. Diagnosis is made by transabdominal ultrasound followed by transvaginal ultrasound if necessary. Approximately 95% of placenta previa can be diagnosed in this manner. Placenta previa is due to abnormal implantation of the placenta. It can be classified as total, marginal or low-lying. The incidence is about 1 in 200. Risk factors for it include prior c-section, grand multiparity, advanced maternal age, multiple gestation, and prior placenta previa. It presents as painless bright red bleeding that often ceases in 1-2 hours with or without uterine contractions. The fetus is usually not in distress. It is diagnosed with transabdominal or transvaginal ultrasound, which will show an abnormally positioned placenta.

Bottom Line: DKA occurs due to the absence of insulin.COMBANK Insight : Questions regarding DM are repeatedly seen on COMLEX year after year. This is one topic that you should review inside and out before test day. Cases (such as the one given here) may be very general and leave you guessing. Look for slight clues in the case stems to help you make a correct diagnosis. In this case, noticing the electrolyte disturbances in this patient should have made you suspicious for DKA.

true Diabetic ketoacidosis (DKA) is caused by insulin deficiency. In the absence of insulin, counterregulatory hormones such as glucagon, growth hormone, and catecholamines cause the rapid breakdown of triglycerides into free fatty acids and gluconeogenesis, which is the primary cause for elevated glucose levels in patients suffering from DKA. Beta-oxidation of these free fatty acids results in the formation of ketone bodies, which is responsible for the fruity-smelling breath in DKA patients. Metabolism in DKA shifts from that of the normal fed state (characterized by carbohydrate metabolism) to that of a fasting state, which is defined by fat metabolism.

McBurney point is the name given to the point over the right side of the abdomen that is one-third of the distance from the anterior superior iliac spine to the umbilicus.

true Tenderness at the McBurney point suggests the evolution of acute appendicitis to a later stage and thus the increased likelihood of rupture. Other abdominal processes can also sometimes cause tenderness at the McBurney point, including any kind of colonic or ileal inflammation or a renal stone passing through the adjacent ureter. Thus, this sign is highly useful but neither necessary nor sufficient to make a diagnosis of acute appendicitis. The anatomical position of the appendix is also highly variable (for example, in retrocaecal appendix, an appendix behind the caecum), which also limits the use of this sign as many cases of appendicitis do not cause point tenderness at McBurney point. For most open appendectomies (as opposed to laparoscopic appendectomies), the incision is made at the McBurney point. CT scan of the abdomen and pelvis with contrast is the most effective imaging study to either confirm acute appendicitis or disclose some other cause of this patient's abdominal pain.

The deposition of copper in the posterior lamellae of Descemet's membrane in the cornea is characteristic of Wilson disease (Kayser-Fleischer rings). Wilson disease can be treated with penicillamine.

true The deposition of copper in the posterior lamellae of Descemet's membrane in the cornea is characteristic of Wilson disease. This entity is also known as hepatolenticular degeneration and can affect the liver, nervous system, and other organs by copper deposition. It is autosomal recessive inherited. Laboratory evaluation would show low serum ceruloplasmin and high urinary copper. Many individuals present with chronic liver disease and Parkinson-like neurologic manifestations. Treatment is with penicillamine to chelate the copper.

Mixed incontinence is a combination of any of these types of incontinence.

true

A hordeolum,

-------- or stye, is an infection of the eyelid. It is usually caused by Staphylococcus aureus and can be treated with warm compresses and dicloxacillin.

Achondroplasia

---------is associated with increased paternal age. It is due to a mutation in fibroblast growth factor. Patients present with short limbs but typically have normal head and trunk size.

The most nonphysiologic cause of DUB is polycystic ovarian syndrome (PCOS), which is characterized by excessive androgen release and a luteinizing hormone (LH)/follicle-stimulating hormone (FSH) ratio of greater than ?

2:1. Polycystic ovarian syndrome is characterized by anovulation or oligoovulation and hyperandrogenism. These patients often present with unpredictable cycles and/or infertility, hirsutism with or without hyperinsulinemia, and obesity.

-------may be associated with ingestion of tetracyclines. Tetracyclines become deposited in growing bone by binding to divalent cations, such as calcium, which leads to the inhibition of bone growth.

Bone damage

A 31-year-old, G2P1001, Hispanic female at 21-3/7 weeks gestation presents to the obstetric clinic for evaluation due to shortness of breath and uterine contractions. This pregnancy is complicated by increased amniotic fluid index (26.2 cm) at her anatomy ultrasound two weeks ago. Her previous pregnancy was complicated by gestational diabetes, and she has a strong history of diabetes in her family. Upon physical examination, the fundal height is 28 cm. The most likely etiology for her increased amniotic fluid is A. congenital varicella infection B. duodenal atresia C. gestational diabetes mellitus D. hydrops fetalis E. twin-to-twin transfusion syndrome5

C. gestational diabetes mellitus olyhydramnios is an excessive volume of amniotic fluid. It has been associated with an increased risk of various adverse pregnancy outcomes, including preterm birth, placental abruption, and fetal anomalies. Polyhydramnios should be suspected clinically when uterine size is large for gestational age. Prenatal ultrasound is the first-line modality for diagnosis. The diagnosis of polyhydramnios is based upon sonographic visualization of increased amniotic fluid volume (AFV). It is diagnosed when there is a single deepest pocket ≥ 8 cm and an amniotic fluid index (AFI) ≥ 24 cm. The most common cause of severe polyhydramnios are fetal anomalies (often associated with an underlying genetic abnormality or syndrome), while maternal diabetes, multiple gestation, and idiopathic factors are more often associated with milder cases. Polyhydramnios has been associated with fetal anomalies in most organ systems. All of the above are causes of polyhydramnios. However, in this case, the most likely etiology in this patient is gestational diabetes mellitus (GDM). The mother had GDM during her first pregnancy and is at a higher risk of developing it again during her second pregnancy. Just like increased serum levels of glucose causes polyuria in adults, a similar effect occurs in the fetus and amniotic fluid is fetal urine. Answer A: Congenital varicella infection (CVS) can lead to spontaneous abortion, intrauterine fetal demise, and varicella embryopathy. Congenital varicella syndrome is characterized by cutaneous scars, limb hypoplasia, muscle atrophy, malformed digits, psychomotor retardation, microcephaly, cortical atrophy, cataracts, chorioretinitis, and microphthalmia. Ultrasound findings suggestive of CVS can include polyhydramnios, hydrops, echogenic foci, cardiac malformations, limb deformities, microcephaly, and intrauterine growth retardation. Answer B: While duodenal atresia should be considered in your differential diagnosis, the question provides information that should be highly suspicious of redevelopment of gestational diabetes during this mother's second pregnancy. The amount of fluid surrounding the fetus is dependent on the balance between fetal swallowing and fetal urination. In the setting of duodenal atresia, the fetus cannot swallow. This leads to increased levels of amniotic fluid due to decreased swallowing capabilities. Ultrasound findings that suggest intestinal atresia include polyhydramnios, a dilated loop of bowel, hyperechoic bowel, and ascites. Proximal atresias are more likely than distal lesions to be detected prenatally. Distal lesions usually are detected after birth. On prenatal ultrasound, duodenal atresia usually has the characteristic double bubble appearance. Answer D: Hydrops fetalis is a syndrome that leads to increased levels of fluid in the fetus. Hydrops is diagnosed by the accumulation of fluid in at least two sites in the neonate. These sites include fetal skin edema, pleural effusion, pericardial effusion, and ascites. Hydrops fetalis is also commonly associated with polyhydramnios. Most cases of hydrops are from non-immune causes. Some common causes of hydrops include twin-to-twin transfusion syndrome, chromosomal abnormalities, cardiac defects and arrhythmias, fetal anemia, and TORCH infections. The patient described in this scenario has no risk factors for any of these causes of hydrops .Answer E: The scenario does not mention a twin pregnancy here. However, if a twin pregnancy were noted, twin-to-twin transfusion syndrome (TTTS) could be a possibility. TTTS is a syndrome whereby one twin becomes the donor and the other is the recipient via vascular communications between the fetuses. The donor twin tends to be growth-restricted, have decreased fluid, and be very stressed. The recipient tends to be larger, have increased fluid (polyhydramnios), and can tend to have heart failure from fluid overload. TTTS is a complication seen in about 15% of monochorionic twin pregnancies. Bottom Line: Although there are many causes of polyhydramnios, gestational diabetes should be considered a cause in a woman presenting with risk factors for developing GDM, especially if they developed it in a prior pregnancy. While it is not the most common cause, in this setting it is the most likely.

-------generally presents with right upper quadrant pain and nausea and vomiting, but without fever. It may lead to complications such as cholangitis or pancreatitis.

Choledocholithiasis generally presents with right upper quadrant pain and nausea and vomiting, but without fever. It may lead to complications such as cholangitis or pancreatitis.

----- esophagus is the radiological finding for diffuse esophageal spasm. This condition presents as chest pain triggered by stress, hot/cold, and acid.

Corkscrew

Newborn with cranium shaped like a parallelogram You answered this question incorrectly. A. Compression B. Flexion/ extension strain C. Lateral strain D. Torsion E. Vertical strain

Correct answer: C Lateral strain Lateral strain occurs when the sphenoid deviates laterally in relation to the occiput. Rotation occurs about two vertical axes through the center of the foramen magnum and the sphenoid. The cranium will have a parallelogram-like shape on the exam.

A 42-year-old male presents to your office complaining of erectile dysfunction. His past medical history is significant for poorly controlled diabetes and peripheral vascular disease. He currently takes metoprolol and tamsulosin. He tells you he sometimes wakes up with an erection. What is the most likely cause of his complaint? A. diabetes B. metoprolol C. peripheral vascular disease D. psychological E. tamsulosin

D. psychological Bottom Line: The distinction between psychological and organic erectile dysfunction is based on the presence of nocturnal or early morning erections, which are present with psychological erectile dysfunction. The most likely diagnosis is psychological erectile dysfunction (ED). ED can be found in 10% to 25% of middle-aged and elderly men. It can be classified as failure to initiate (psychological, endocrinologic, neurologic), failure to fill (arteriogenic), or failure to store (veno-occlusive). Risk factors include diabetes, atherosclerosis, beta-blockers, alpha-blockers, selective serotonin reuptake inhibitors, tricyclic antidepressants, diuretics, hypertension, heart disease, and surgery or radiation for prostate cancer and spinal cord injury. The distinction between psychological and organic ED is based on the presence of nocturnal or early morning erections. If these are present, the ED can be classified as nonorganic and is likely psychological in nature. Patients with psychological ED may benefit from psychotherapy or sex therapy involving discussion and exercises with the appropriate partner.

Hemochromatosis is accumulation of?

Hemochromatosis is the abnormal accumulation of iron in parenchymal organs, leading to organ toxicity. This is the most common inherited liver disease in white persons and the most common autosomal recessive genetic disorder. Patients with hemochromatosis are at an increased risk of developing hepatocellular carcinoma. This patient is demonstrating symptoms consistent with this diagnosis and should be evaluated by CT of the abdomen before anything else is performed.

----- typically presents with multiple shallow, painful ulcers with recurrence and resolution. Treatment of choice is acyclovir. Genital ulcers are typically caused by -----

Herpes simplex virus herpes simplex type 2.

------burns should be initially treated with copious irrigation with tap water, followed by calcium gluconate gel application.

Hydroflouric acid

Incomplete abortion

Incomplete abortion is when some, but not all, products of conception are passed. An open cervical os and normal ultrasound will be found. Treatment is with dilatation and curettage.

------ is similar, in that the patient can also initiate breaths; however, the machine does not support these breaths with a preset tidal volume. Instead, the machine supports the patient's breaths by a preset pressure and retimes the breathing rate based on the patient's own breathing pattern. There is also a backup rate setting with IMV. This is not very commonly used except in circumstances of weaning.

Intermittent mandatory ventilation, or IMV,

------ can present with crying and bilious vomiting in children too young to speak. They typically lie in positions where the knees are drawn to the chest. There may also be mention of currant jelly stools. Look for a palpable sausage-like mass on physical examination.

Intussusception

Procainamide is a class Ia antiarrhythmic. Class Ia and Ic antiarrhythmics, beta-blockers, and amiodarone should be avoided in tricyclic antidepressant overdose, as they tend to enhance the effects of toxicity. ----- is the drug of choice in tricyclic antidepressant toxicity with arrhythmia.

Lidocaine

------is an antiparasitic medication that is used to treat pinworm, whipworm, hookworm, and roundworm infections. Its mechanism of action is to inhibit microtubule formation and glucose uptake. It has no role in the treatment of fungal infections.

Mebendazole

Slipped capital femoral epiphysis (SCFE) is most common in the adolescent period. Males have 2.4 times the risk for this disorder as compared with females. ---- is a risk factor because it places more shear forces around the proximal growth plate.

Obesity

----- is a catecholamine-secreting tumor that is not associated with Marfan syndrome. Symptoms include episodic headaches, sweating, and palpitations in addition to hypertension. These tumors can occur in association with multiple endocrine neoplasia 2A and 2B, neurofibromatosis, and von Hippel-Lindau syndrome.

Pheochromocytoma

------- are a common cause of shoulder pain that is exacerbated with overhead activity. Patients may awaken from sleep secondary to the pain. Rotator cuff tears present with decreased active range of motion, secondary to loss of muscle strength.

Rotator cuff tears

Bottom Line: Troponin I is the most specific cardiac biomarker indicating myocardial infarction.

TRUE

The National Committee for Quality Assurance (NCQA) ----

The National Committee for Quality Assurance (NCQA) is designed to improve health care quality and manages voluntary accreditation programs for individual physicians and medical groups. The National Practitioner Data Bank (NPDB) provides information concerning malpractice payments, adverse licensure, withdrawal of clinical privileges, and other negative actions taken against individual health care practitioners.

Threatened abortion

Threatened abortion is any vaginal bleeding before 20 weeks' gestation. Symptoms are consistent with minimal bleeding and cramping. A closed cervical os and a normal gestational sac will be seen. Expectant management and pelvic rest comprise the treatment regimen.

------are common in infants ages 0-2 weeks and classically present with respiratory compromise during feeding, aspiration pneumonia, and the inability to pass a nasogastric tube into the stomach.

Tracheoesophageal fistulas

Ring-enhancing lesions on head CT are found in toxoplasmosis or CNS lymphomas seen in AIDS. true or false?

True

true

With salicylate toxicity, the metabolic disturbances are characteristic and therefore highly testable. Salicylates directly stimulate the respiratory center of the brain resulting in early decrease in CO2 through exhalation and subsequent initial respiratory alkalosis. This progresses to a positive anion gap metabolic acidosis or more commonly a mixed primary respiratory alkalosis-primary metabolic acidosis occurs. The later acid/base disturbance is through both its action as a weak acid and its effect as an uncoupler of the electron transport chain. These metabolic effects are of paramount importance as it influences both direct treatment and supportive care.As salicylates compete with hydrogen ions for urinary excretion, alkalinizing the urine increases urinary clearance of aspirin and its products. Activated charcoal should also be given especially if within 2 hours of ingestion. If enteric-coated aspirin was taken, repeated charcoal may be given. Hemodialysis may be indicated with sodium bicarbonate for severe acidosis and improved removal of salicylates from the body. Other supportive measures include intubation whereby close monitoring of acid base status must be taken due to the body's inability to use respiratory compensation for acidosis with continuous mechanical ventilation.

During an -------- cycle, the corpus luteum does not form, resulting in the absence of normal cyclical progesterone secretion. This leads to the continuous unopposed production of estradiol, stimulating endometrial overgrowth. Without progesterone, the endometrium continues to proliferate and eventually outgrows its supply of blood. The end result is overproduction of uterine blood flow. Ovulatory DUB occurs due to prolonged progesterone secretion.

anovulatory

The -------is a branch of the median nerve that supplies the deep muscles on the front of the forearm, except the ulnar half of the flexor digitorum profundus. Injury to the AIN can be seen with orthopaedic surgery and the use of Kirschner (K) wires that penetrate through the anterior cortex of the proximal ulna. Injury to the AIN, a branch of the median nerve, would lead to loss of ability to flex the thumb interphalangeal joint. As might be expected, other symptoms involve weakness in the muscle innervated by the AIN, including the flexor digitorum profundus muscle to the index finger and the pronator quadratus of the distal forearm.

anterior interosseous nerve (AIN) Bottom Line: The anterior interosseous nerve (AIN), a branch of the median nerve, is responsible for motor innervation of the flexor pollicis longus, flexor digitorum profundus muscle to the index finger, and the pronator quadratus of the distal forearm.

Children with attention deficit/hyperactivity disorder are at an increased risk of developing ------

antisocial personality disorder.

This patient presents following an episode of syncope. While the differential diagnosis for syncope is large, ruling out causes associated with sudden death, such as ---------is paramount. This patient has a heart rate of 40/min, indicating that a bradyarrhythmia is the most likely cause. This can be confirmed with an ECG. Etiologies include sinoatrial (SA) or atrioventricular (AV) nodal dysfunction, as well as other conductive causes. Treatment of symptomatic bradycardia is managed by pacemaker placement. Asymptomatic bradycardia is not treated.

arrhythmia,

The most common form of nephrolithiasis is -----

calcium oxalate precipitation. Treatment includes vigorous hydration, although some stones require surgical intervention to extract. Urinalysis shows hematuria and an alkaline pH. These stones are radiopaque.

Symptoms of ------ withdrawal include: Depression, which can often be severe during initial withdrawal and include suicidal ideation Anxiety Fatigue Difficulty concentrating Anhedonia Increased appetite Increased sleep with increased dreaming secondary to increased REM sleep period

cocaine

Bottom Line: Non-reassuring fetal pulse rate patterns are the predominant sign, suggesting impending or actual uterine rupture. what should be your management plan?

internal fetal monitoring

The child is suffering from mastoiditis, with typical symptoms of ear pain, fevers, and swelling of the mastoid causing the ear to protrude out. Mastoiditis is a complication of otitis media. The treatment of choice for mastoiditis is-----

intravenous antibiotic therapy.

A commonly used muscarinic antagonist is ----, which causes bronchodilation and is typically used in patients with chronic obstructive pulmonary disease.

ipratropium

Parinaud oculoglandular syndrome is the result of infection with Bartonella henselae, which is often transmitted from contact with ----- and presents with enlarged submandibular and preauricular lymph nodes and conjunctivitis.

kittens

common site of trauma in sexual assault, but injury occurs here less often than at the posterior fourchette

labia minor

Decreased alpha-1 antitrypsin levels are associated with

liver disease and emphysema.

Symptoms of ------ withdrawal include: Dysphoria Nausea or vomiting Myalgias Lacrimation or rhinorrhea Pupillary dilation Piloerection Diaphoresis Diarrhea Yawning Fever Insomnia

opiod

Bottom Line: New-onset hypertension with proteinuria after 20 weeks' gestation is diagnosed as -----

preeclampsia.

A history of recurrent urinary tract infections is associated with -----stones (made of Mg-NH4-PO4).

struvite

The urine is acidic with cystine stones. Basic urine is associated with calcium oxalate and -----stones.

struvite

Arsenic poisoning can be caused by pesticides or contaminated groundwater. It presents with severe headaches, abdominal pain, diarrhea, delirium, convulsions, and breath that smells like garlic. It can be treated with chelating agents such as ------

succimer or dimercaprol.

The most likely diagnosis in this patient is injury to the superficial peroneal nerve. There are 5 nerves that cross the ankle joint: superficial peroneal nerve, deep peroneal nerve, tibial nerve, sural nerve, and saphenous nerve. The superficial peroneal nerve crosses the fibula approximately 10 cm proximal to the lateral malleolus and can be injured in fibular fractures. This patient is complaining of right leg pain, and x-rays demonstrate a fibular fracture at the approximate location of the superficial peroneal nerve. Physical exam shows decreased sensation in the distribution of the superficial peroneal nerve only. The superficial peroneal nerve supplies sensation to the dorsum of the foot. Ankle injuries commonly lead to fibular fractures. The superficial peroneal nerve supplies sensation to the dorsum of the foot and can be injured in distal fibular fractures.

superficial peroneal nerve.

A 5-day-old male infant is brought by his mother to the emergency department with a diffuse rash. The mother states that the rash began 1 day earlier and was located on buttocks and hands but has now spread to the entire body (see exhibit). The patient is febrile with a temperature of 38.7°C (101.7°F) and has been feeding less than normal. Nikolsky sign is positive. What is the underlying mechanism causing this disorder?

toxin production Staphylococcal scalded skin syndrome staphylococcal scalded skin syndrome (SSSS), also known as pemphigus neonatorum or Ritter disease typically presents in newborns and is caused by the release of an exfoliative toxin by Staphylococcus aureus. This newborn presents with staphylococcal scalded skin syndrome (SSSS), also known as pemphigus neonatorum or Ritter disease.It is caused by exfoliative toxins produced by Staphylococcus aureus. Newborns are especially susceptible to this disorder, which typically occurs at 3 to 7 days of age. Affected infants are febrile and irritable, with diffuse blanching erythema often beginning around the mouth. Flaccid blisters appear 1 to 2 days later, especially in areas of mechanical stress including flexural areas, buttocks, hands, and feet. The disease is produced by epidermolytic exotoxins A and B of S aureus. These toxins are proteases that cleave desmoglein-1, which is responsible for holding the stratum granulosum and spinulosum together, leading to the formation of these flaccid blisters. Management is with supportive care in addition to parenteral antistaphylococcal antibiotics. Because many of the strains of SSSS are penicillin resistant, treatment is generally with oxacillin, nafcillin, or vancomycin. The prognosis of SSSS is excellent, with complete resolution usually within 10 days for infants.

------presents as a painless nodule near the metacarpophalangeal joint and can cause locking or catching of the digits. Conservative treatments are attempted before corticosteroid injections or surgery.

trigger finger a type of stenosing tenosynovitis

Pregnancies affected by Down syndrome (trisomy 21) generally have increased serum β-hCG and inhibin-A levels as well as decreased estriol levels. Markedly elevated α-fetoprotein levels are associated with neural tube defects. Decreases in α-fetoprotein, estriol and β-hCG are associated with pregnancies complicated by ----

trisomy 18.

----disease is avascular necrosis of the proximal femoral head resulting from a compromise of the tenuous blood supply to this area. Treatment consists of containment of the hip within the acetabulum via bracing or surgical acetabular reconstruction.

true

ADAMTS13 is used to evaluate thrombotic thrombocytopenic purpura (TTP). Patients with TTP will have low platelets due to peripheral consumption with destruction of RBCs seen on peripheral smear as schistocytes. This patient has no schistocytes on peripheral smear. Additionally, it is usually associated with fever, renal failure, and altered mentation. This patient has none of those symptoms.

true

ASA, cilostazol and thromboxane inhibitors may improve symptoms. Anticoagulants such as heparin, low molecular weight heparins and warfarin may be used to prevent clot formation. Cilostazol should be avoided in patients with CHF.

true

ASA, cilostazol, and thromboxane inhibitors may improve symptoms. Anticoagulants such as heparin, low molecular weight heparins, and warfarin may be used to prevent clot formation. Cilostazol should be avoided in patients with CHF.

true

Abnormalities of the common bile duct are consistent with the diagnosis of primary sclerosing cholangitis, not Crohn disease.

true

Abruptio placentae is associated with hypertension, abdominal/pelvic trauma, tobacco or cocaine use, previous abruption, rapid decompression of an overdistended uterus, and excessive stimulation.

true

Accelerations are reassuring and represent a physiologic response to fetal movement.

true

Although a computed tomography (CT) of the chest may reveal either an underlying thymoma or lung cancer (if Lambert-Eaton syndrome was suspected), this test would not rule in the primary diagnosis. CT is part of further workup for patients with MG to evaluate for the presence of thymoma as thymectomy may result in improvement of disease.

true

An acceleration is a physiologic response to fetal movement and represents an active, well-oxygenated fetus.

true

Aneurysm diameter is the strongest predictor of aneurysm rupture, with risk increasing markedly at aneurysm diameters greater than 5.5 cm.The decision about whether to repair an abdominal aortic aneurysm requires consideration of a balance of risks, including aneurysm rupture if surgery is not performed and death due to aneurysm repair itself, as well as consideration of an individual patient's probable life expectancy.

true

Answer A: Ataxic respiration is an abnormal pattern of breathing characterized by complete irregularity of breathing, with irregular pauses and increasing periods of apnea. It indicates a poor prognosis. Ataxic respirations mostly occur following damage to the medulla oblongata secondary to strokes or traumatic brain injury and carry a very poor prognosis. It differs from Cheyne-Stokes in that Cheyne-Stokes is more regular and has similar tidal volumes compared with ataxic respirations. Ataxic respirations are completely irregular and have variable breaths and pauses.

true

Answer A: Buerger disease is a nonatherosclerotic, segmental, inflammatory disease in the small and medium-sized vessels of the hands and feet. It effects smokers and typically those <45 years old. This is a very probable diagnosis, but not the best possible diagnosis. Buerger disease can result in gangrene formation and amputation; however, this patient is 60 years old and has peripheral vascular disease. Patients also initially complain of a claudication type of pain that is better with rest and worse with activity. This patient states his pain has been a constant dull ache.

true

Answer A: Candida albicans accounts for most cases of infective endocarditis in patients with long-term indwelling catheters, malignancy, AIDS or organ transplantation.Answer B: S. aureus is the most common cause of acute bacterial endocarditis in patients with a history of IV drug abuse.Answer D: Strep bovis bacteremia is commonly associated with gastrointestinal malignancies such as colon cancer.Answer E: Strep viridans is most commonly found in patients with left-sided subacute bacterial endocarditis.Bottom Line: The most common organism infecting prosthetic valves is staph epidermidis

true

Answer A: The Adson test checks for thoracic outlet syndrome. The examiner monitors the patient's pulse while extending the elbow, extending, externally rotating, and slightly abducting the patient's shoulder. The patient then takes a deep breath and turns his or her head to the ipsilateral shoulder. If the radial pulse becomes weakened or absent, this indicates a positive test.

true

Answer B: Identification occurs when someone unconsciously patterns behavior after someone more powerful or influential. An example would be a heroin addict who receives successful mentoring from a drug-abuse specialist and goes on to become a counselor for drug abusers. Identification can be positive or negative.

true

Answer E: A complete abdominal ultrasound will assess the liver, the kidneys, the aorta, the pancreas and look for ascites. This is unnecessary at this time as the concern in this patient should be for ectopic pregnancy. If, for some reason she was incorrect, and she was not pregnant, then there could be concern for ovarian torsion. This test does not routinely evaluate the ovaries or uterus and would not give you any further information as to the cause of this patient's left lower quadrant pain.

true

Aortic regurgitation is an incompetence of the aortic valve. Common causes include rupture secondary to endocarditis, aortic root dilation, and hypertension. Patients typically present with symptoms of left heart failure and a wide pulse pressure. Cardiac auscultation reveals a diastolic decrescendo murmur heard at the right second intercostal space. Late diastolic rumbles (Austin-Flint murmur) and bounding pulses are typical. Treatment is valvular repair in acute cases. Chronic cases may be compensated, and medical therapy with preload and afterload reducers is appropriate.

true

As noted in the previous question, lorazepam is the first-line medication that should be used for patients refractory seizures or patients in status epilepticus. Alternatives for initial therapy are diazepam and midazolam (if no IV access is available). The patient should have a second IV placed. If a patient does not respond to lorazepam, then a second medication should be given through the second IV. Options for the second medication include fosphenytoin, phenytoin, valproic acid, or levetiracetam.

true

Asperger disorder does not involve mental impairment or the loss of language skills.

true

Asperger-A DEVELOPMENTAl disorder, affecting inability to effectively socialize and communicate. Asperger syndrome is a condition on the autism spectrum with generally higher functioning

true

Aspirated foreign bodies are common in young children and often present with stridor and coughing fits. Removal of the foreign body is required and is most commonly accomplished via bronchoscopy. While in clinical practice either rigid or flexible bronchoscopes can be used, the most correct choice would be rigid bronchoscopy, as it is the safest and most reliable.

true

Aspirin is indicated in all acute coronary syndrome cases unless there is a history of hypersensitivity.

true

Bed rest is rarely the answer for any back pain. It is important for the patient to keep moving in ways that do not stress or put her spine in danger.

true

Benzodiazepines are GABA agonists and used as anxiolytic medications; intoxication would demonstrate amnesia, sleep, and respiratory depression.

true

Bottom Line: Elderly patients in respiratory distress should be intubated and placed on mechanical ventilation unless otherwise stated in an advance directive, or confirmed by the medical power of attorney.COMBANK Insight : During your exam (and when in the hospital) always be conservative regarding ethical issues. Lifesaving measures should be performed unless there is substantial evidence in writing suggesting the patient prefers otherwise.

true

Bottom Line: First-line medications for the treatment of osteoporosis include alendronate, risedronate, zoledronic acid, and denosumab. Medications used to treat osteoporosis are classified into 2 primary categories. The first includes medications that help to stimulate bone formation, such as vitamin D and bisphosphonates. The second includes medications that reduce bone resorption, such as estrogen, bisphosphonates, calcitonin, calcium, and vitamin D.

true

Bottom Line: Know the diagnostic criteria for type 2 diabetes mellitus, which is diagnosed either by a random blood glucose sample of greater or equal to 200 mg/dL in addition to symptoms, fasting plasma glucose level of greater than or equal to 126 mg/dL on 2 separate occasions, glucose tolerance test level above 200 mg/dL, or hemoglobin A1c above 6.5%.COMBANK Insight : Diabetes is far and away the most commonly tested endocrine disorder on COMLEX. Other commonly tested topics include thyroid disorders, followed by cortisol abnormalities, diseases involving the hypothalamus, and pituitary abnormalities.

true

Bottom Line: Lateral epicondylitis is a common overuse syndrome that presents with lateral elbow pain exacerbated with resisted wrist extension. Resolution may take patients upwards of 6-9 months regardless of treatment.

true

Bottom Line: The most common pathogen for septic arthritis in all individuals, including IV drug abusers, is Staphylococcus aureus.COMBANK Insight : An elevated erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) is useful in following response to therapy, as well as in detecting an acute process in chronically affected joints.

true

Bottom Line: The murmur of a ventricular septal defect is a harsh pansystolic murmur at the left lower sternal border. An atrial septal defect, ventricular septal defect, or patent ductus arteriosus can progress to Eisenmenger syndrome, which is reversal of a left-to-right shunt to a right-to-left shunt, causing cyanosis.COMBANK Insight : It is important to review the most common characteristics of different types of heart murmurs. COMLEX exams are now incorporating more audio files; therefore, it would be wise to be able to diagnose each murmur based on how it sounds.

true

Bottom Line: The pathogenesis of primary open angle glaucoma involves elevated intraocular pressure resulting in retinal nerve fiber layer loss.COMBANK Insight : Activities of daily living can be affected by many sources of pathology in geriatric patients. The loss of peripheral vision can significantly impact an individual's ability to function independently. Patients should be screened regularly for insidious processes such as cataract formation, age-related macular degeneration, and glaucoma.

true

Bottom Line: Tinnitus is often associated with dysfunction of cranial nerve VIII and the most likely cranial bone dysfunction is the temporal bone.COMBANK Insight : Cranial dysfunctions are commonly tested subjects. Know the most common symptoms associated with each cranial bone dysfunction.

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Bottom Line: Understanding the difference between exudative and transudative pleural effusions is of paramount importance and is a frequently tested subject. A pleural effusion qualifies as an exudate with the one or more of the following criteria: pleural to serum lactate dehydrogenase (LDH) ratio of greater than 0.6, pleural to serum protein ratio greater than 0.5, or pleural fluid LDH greater than two-thirds of the normal upper limit of serum LDH.

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Bottom Line: Urinary tract infection is the most common cause of fever on postoperative day 4 in patients requiring Foley catheterization.COMBANK Insight : The COMLEX commonly tests subjects that are commonly seen on medical student clinical rotations. Postoperative fever is a case that you are likely to see on the floors in the hospital on your surgery rotation.

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Bottom Line: VWD is the most common inherited bleeding disorder.COMBANK Insight : Many questions on COMLEX will deal the most common presentation of a certain disease. Sometimes just knowing what the most common conditions are will score you easy points on test day.

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Bottom Line: Vitamin B12 deficiency is associated with peripheral sensory neuropathy, decreased deep tendon reflexes, and fatigue. The neuropathy is often described as "stocking glove," which does not follow a standard dermatome.

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Bottom Line: When discussing penetrating neck trauma, the neck is divided into 3 zones. Unstable patients go to the operating room for exploration and treatment, while stable patients presenting with injuries to zone 1 or 3 undergo further testing, including chest x-ray, angiography, esophagoscopy, and laryngoscopy.

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Bottom Line: Women who suffer from Paget's disease of the breast frequently present with a chronic, eczematous rash on the nipple and adjacent areolar skin, which is highly suggestive of malignancy.

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Bottom Line: X-rays are indicated to help diagnose possible ankle fractures after injury based on the Ottawa Ankle Rules. Physical exam should always include assessment of the ipsilateral knee to rule out proximal fibula fractures.

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COMBANK Insight : The American Heart Association (AHA) has spent years researching their algorithms for basic life support (BLS) and advanced cardiac life support (ACLS). Test questions can be on the particular steps, as well as the order of the steps.

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Cat scratch disease is a multisystem disease that often presents with subacute lymphadenopathy. Inquire about cat exposure in patients with unexplained lymphadenopathy.

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Certain medications such as digitalis, beta-blockers, adenosine, and calcium channel blockers are contraindicated in WPW as they increase the refractory period of the AV node, thus increasing conduction through the accessory pathway. In the setting of an accelerated atrial tachycardia such as atrial fibrillation, 1:1 conduction through the accessory pathway can be deadly.

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Chapman's points for the colon occur over the lateral thigh along the iliotibial band.

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Chapman's reflexes for the kidneys are located anteriorly, 1 inch superior and 1 inch lateral to the umbilicus, or posteriorly, between the spinous and transverse processes of T12 and L1.

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Children are typically exposed to environmental lead through ingestion and inhalation. The most common sources include chips of paint or lead dust from lead-painted surfaces. Although the United States discontinued the use of lead in paint back in the 1970s, it can still be found in paint in older homes. Often, older pain chips and these solid particles can be inadvertently eaten by younger children. Symptoms of lead poisoning can include neurocognitive deficits, acute encephalopathy (leading to seizures), hearing loss, and peripheral neuropathy. Lead can also have effects on the renal, GI, endocrine, and hematologic systems.

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Chronic granulomatous disease presents with bacterial and fungal infections early in life and granulomas on the skin are also common. About a third will have granulomas in the GI tract that may or may not cause obstruction. This can be readily tested for with the nitroblue tetrazolium test.

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Clavicular fractures are the most common broken bones in newborns, especially large neonates. Of these, greenstick fractures are the most frequent and are usually asymptomatic. Newborns may present with decreased or absent movement and pain or tenderness on movement of the arm on the affected side, deformity and discoloration over the fracture site, and crepitus or irregularity along the clavicle. Treatment is directed at minimizing the newborn's pain or discomfort. If the newborn with clavicular fracture is in pain, the affected arm should be immobilized, with the arm abducted more than 60 degrees and the elbow flexed more than 90 degrees. In this patient, there is no mention of crepitus felt over the clavicle, which would be more consistent with this diagnosis.

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Computed tomography can be useful in patients who are obese or when an abscess or perforation is suspected. It can be accurate in determining acute cholecystitis but has a lower sensitivity than cholescintigraphy. Computed tomography would be the imaging test of choice for undifferentiated abdominal pain or if cholescintigraphy was not available.

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Consumption of maternal blood occurs in 2 settings, one of which is in the peripartum period where the newborn swallows maternal blood during passage through the vaginal canal, and the second occurs during breastfeeding, whereby the infant swallows blood from cracked or traumatized nipples. Diagnosis is suspected clinically and can be confirmed by the Apt test (hemoglobin alkaline denaturation test) whereby maternal blood turns brown/yellow after application, confirming a maternal source. This patient is too old for perinatal blood consumption, and he is no longer breastfed.

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Copper deficiency can be seen in patients with Menkes, malabsorption due to a number of causes, milk formula with low copper, chronic dialysis, and too much zinc ingestion. Patients present with fragile abnormal hair, depigmented skin, ataxia, neuropathy, cognitive defects, edema, and osteoporosis. Lab findings typically include a microcytic anemia and neutropenia. Think about this in a patient with microcytic anemia that gets worse with iron supplementation.

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Corticosteroids have been shown to be highly beneficial for patients suffering from myasthenia gravis, as well as those suffering from polymyositis.

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Coxsackie A virus is the causative agent of hand-foot-and-mouth disease, which can be diagnosed based on the classic presentation noted in this question. The disease presents with characteristic painful ulcers in the mouth and a maculopapular vesicular rash on the palms and soles, sometimes involving the buttocks. The disease is self-limited, although a mouthwash containing a local anesthetic can be used to relieve oral pain.

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DIC presents with diffuse clotting, which generally results in a loss of fibrinogen. This patient has a normal fibrinogen, virtually eliminating the possibility of DIC. He also has normal PT and PTT which indicate that he has normal amounts of clotting factors. The PT and PTT should be prolonged in DIC due to consumption.

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Damage to the eighth cranial nerve would cause sensorineural, not conductive, hearing loss, and can occur as a result of aminoglycoside toxicity.

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Delirium tremens typically occurs between 48 and 96 hours after cessation of alcohol use. Symptoms include psychomotor agitation, tachycardia, hypertension, fever, and diaphoresis. The patient would have abnormal vital signs and have altered sensorium consistent with delirium.

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Familial benign pemphigus (ie, Hailey-Hailey disease) is characterized by the presence of vesicular lesions and crusting erythematous plaques typically over the genital area and in the skin folds, such as the groin and axilla.

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Febrile non-hemolytic transfusion reactions are benign transfusion reactions that can be prevented by using leukoreduced blood products. Treatment includes acetaminophen. There is no evidence for pre-treatment with antihistamines and/or acetaminophen.

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Fetal anemia can raise the baseline and cause fetal tachycardia. If the fetus is severely anemic, a sinusoidal pattern can appear. This would be demonstrated by a fetal heart rate with sine wave oscillations.

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Fetal head compression activates the vagus nerve and causes early decelerations. Early decelerations are U-shaped decreases in fetal heart rate that begin with the onset of a contraction, reach a nadir with the peak of contraction, and return to baseline as the contraction subsides.

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Fibrin degradation products are increased in DIC due to the fibrinolytic activity at the sites of thrombus formation. The high number of fibrin degradation products interfere with fibrin clot formation and platelet aggregation, further exacerbating hemorrhage.Fibrinogen is also decreased in the following: Liver diseases Hemophagocytic lymphohistiocytosis Anti-fibrinogen antibodies in autoimmune diseases, including systemic lupus erythematosus, rheumatoid arthritis, ulcerative colitis, multiple myeloma

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Flu-like symptoms with a vesicular lesion with a palpable preauricular lymph node is consistent with a primary Herpes Simplex Virus blepharoconjunctivitis. The patient may also have an epithelial keratitis, which would be seen in staining with fluorescein on the cornea. This is a self-limiting condition. However, oral antivirals have been shown to hasten resolution.

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Gallstones are more associated with Crohn's than with Celiac's.

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Historically, direct pulmonary angiography has been the gold standard in diagnosing a pulmonary embolism. However, given the availability of alternative, cheaper, faster, and noninvasive procedures, the most appropriate test to use in a clinical setting is a computed tomography pulmonary angiogram (CTPA).

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Hodgkin disease presents with painless lymphadenopathy and Reed-Sternberg cells.

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Human serum albumin and 6% hydroxyethyl starch are colloid solutions used to expand or maintain intravascular volume and are not preferred for initial fluid management in burn patients.

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In a symptomatic patient presenting with tachycardia, palpitations, dizziness, or chest pain, radiofrequency ablation is a treatment of choice after the appropriate workup. If this therapy is not available, the drug of choice is procainamide or other antiarrhythmic medications that do not prolong AV conduction.

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In the case of allergic contact dermatitis due to poison ivy (Rhus dermatitis), the first-line treatment is either topical corticosteroids in mild cases or, in more severe cases, oral corticosteroids.

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In this situation, the physician is protected if he or she decides to reveal the patient's HIV status to a third party when the physician feels the third party is in danger. It is up to the physician to protect both the privacy of his or her patient, as well as the safety of the third party in danger. The best first step is to encourage the patient to reveal his HIV status to his wife. If he does not comply (as in the case above), the physician is legally protected to reveal the information to the third party at risk.

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Intussusception should be suspected in children ages 3 to 18 months of age who present with abdominal pain, leg withdrawal, and "currant jelly" stools that result from mucosal venous congestion. It is uncommon to see all of these abnormalities in the same patient, so there must be a high index of suspicion in any pediatric patient presenting with abdominal pain.

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MS can be diagnosed with two episodes of symptoms separated in time and evidence of two white matter lesions on imaging. In the image of the MRI, the arrow is pointing to the Dawson's fingers. Women, especially young Caucasian females, are more likely than men to have MS. Treatment of acute exacerbations is with methylprednisolone or prednisone. Treatment of relapsing-remitting disease may include prophylactic agents such as interferon-beta, Fingolimod, glatiramer acetate, and monoclonal antibodies such as Ocrelizumab, Daclizumab, and Alemtuzumab.

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Malignancy has a variable appearance on CT examination of the brain, mostly depending on the location and type of cancer. On an unenhanced CT examination of the brain, a neoplasm may be very hard to see if it is small or in the posterior fossa. Large intracranial tumors will exhibit mass effect and edema and usually will be hypoattenuating to normal brain. With the aid of contrast, a tumor will rim enhance and be more easily seen. MRI imaging of the brain is much more sensitive for the presence of intracranial neoplasia and should be ordered if there is any clinical suspicion, especially for the evaluation of metastatic disease. There is no evidence of malignant or metastatic disease in the included image. Patient age and location of the tumor in a patient with an intracranial mass can be used to generate a differential diagnosis. Adults typically have more metastatic disease to the posterior fossa and primary malignancy, such as astrocytomas, in the supratentorial locations. Children are a bit different, because many primary childhood intracranial neoplasms may occur infratentorially.

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Midgut volvulus occurs from twisting of the mesentery with subsequent compression, bowel obstruction, and ischemia. It most frequently presents with abdominal distension, emesis, and rectal bleeding. Diagnosis may be suggested by plain films with various dilated loops and features of obstruction, but the point of twisting is better seen with a small bowel follow-through or barium enema. Doppler ultrasonography may show compression and inversion of the superior mesenteric artery and superior mesenteric vein relationship. This patient who is largely asymptomatic is unlikely to have a midgut volvulus.

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Mild cognitive impairment is diagnosed when there is objective impairment in functioning, but no impairment in activities of daily living.

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Mitral stenosis is an obstruction across the mitral valve, almost always caused by rheumatic heart disease. Auscultation reveals an opening snap heard after S2 with diastolic rumble and loud S1. Treatment is based on the severity of symptoms, with mitral valve repair or replacement required if a hemodynamic compromise occurs.

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Multiple paragangliomas are observed in patients with mutations in the succinate dehydrogenase (SDH) complex gene, subunits B (SDHB), C (SDHC), and D (SDHD). Paragangliomas are endocrinologically active tumors of the sympathetic nervous system that are histologically identical to pheochromocytomas. These paragangliomas occur in the head and neck region, which distinguishes them from the typical adrenal-tissue locations of pheochromocytomas. Paragangliomas are not part of clinical spectrum of VHL disease.

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N-acetyl-cysteine is the antidote for acetaminophen overdose; it works by replacing the glutathione reductase that is depleted from the metabolites of acetaminophen.

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Occlusion of the visual axis in a child can result in amblyopia. This is the result of sensory deprivation to the visual system of the occluded eye. Such conditions can be the result of congenital cataracts, corneal opacities, difference in refractive error between eyes, and strabismus. In this condition, the visual pathway from the eye to the visual cortex lacks stimulation, and therefore does not develop as it does in the unaffected eye. Early correction of the condition can correct and reverse amblyopia, and often involves patching of the good eye.

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Overflow incontinence is the involuntary release of urine—due to a weak bladder muscle or to blockage—when the bladder becomes overly full, even though the person feels no urge to urinate.

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Parasomnia is a broad term encompassing abnormal movements, behaviors, emotions, perceptions, and dreams that occur while falling asleep, sleeping, between sleep stages, or during arousal from sleep.

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Pauciarticular JIA is the most common form of JIA, is characterized by involvement of less than five joints (generally large joints), and is usually present between 2-3 years of age. These patients are ANA positive, and RF is typically negative. This type of JIA often resolves within six months. These patients are also at risk for uveitis and should be screened by ophthalmology.

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Pectoral traction improves thoracic range of motion, which can improve lymphatic return and is an appropriate treatment for patients who recently underwent abdominal surgery. Contraindication to pectoral traction is a surgical wound in the upper chest and thorax; abdominal surgery is not a contraindication.

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Pregnant women suspected of having Lyme disease should be treated with oral amoxicillin. A typical treatment would include oral amoxicillin 500 mg three times daily for 2-3 weeks. Women who are allergic to amoxicillin would most likely receive 500 mg cefuroxime axetil twice per day.

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Rupture of an intracranial aneurysm and arteriovenous malformations are the 2 most common etiologies of subarachnoid hemorrhage after trauma.

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S2-4 supplies parasympathetic innervation to the lower ureters, bladder and reproductive organs except the ovaries/testes, which receive parasympathetic supply from the vagus nerve.

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Small bowel obstruction presents with intermittent abdominal pain. Patients typically have diarrhea in the early stage and then constipation in the later stage with vomiting. A physical examination will reveal hyperactive bowel sounds, tachycardia, and abdominal distension. There can be significant third spacing of fluids and electrolyte abnormalities as well as the classic findings of air-fluid levels on x-ray. This patient has no abdominal distention or findings consistent with obstruction on exam.

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Streptococcus pneumoniae is the most common cause of pneumonia in most adults. It may present with fever, chills, respiratory distress, and a lobar consolidation on x-ray. It commonly produces rusty brown sputum. It is not as common in patients with cystic fibrosis.

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Stress incontinence is the unintentional or uncontrollable leakage of urine. This order stems from the inability to control your urge to urinate in certain circumstances. It is a serious and embarrassing disorder, which can lead to social isolation. Stress incontinence typically occurs when certain kinds of physical movement puts pressure on your bladder. Laughing, sneezing, coughing, jumping, vigorous exercise, and heavy lifting can all cause stress incontinence. Any pressure placed on the abdomen and bladder can lead to the loss of urine. It is important to remember that the term "stress" is used in a strictly physical sense when describing stress incontinence. Emotional stress is not a factor in this type of urinary disorder. The "stress" refers to excessive pressure on the bladder. An important distinction is that between overactive bladder and stress incontinence. Overactive bladder is a separate condition. In some cases both overactive bladder occurs with stress incontinence and is called mixed incontinence.

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Symptoms of ear fullness and tinnitus describe the classic symptoms of Ménière disease, which can result in sensorineural hearing loss. It can be treated with carbonic acid anhydrase inhibitors such as acetazolamide.

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Syphilis is a sexually transmitted disease caused by T. palladium. There are four stages of the disease: primary, secondary, latent, and tertiary. This initially presents as a painless condition. Darkfield microscopy reveals spirochetes. Secondary phase presents with a maculopapular rash on the palms and soles. The tertiary stage may present with gummas on the skin and tabes dorsalis. The treatment of choice is intramuscular penicillin.

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The Hunter Criteria is used to determine if a patient has serotonin syndrome. That criteria is:The use of an SSRI plus one of the following- Spontaneous clonus- Inducible clonus PLUS agitation or diaphoresis- Ocular clonus PLUS agitation or diaphoresis- Tremor PLUS hyperreflexia- Hypertonia PLUS temperature above 38ºC PLUS ocular clonus or inducible clonus

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The above patient is suffering from status epilepticus since he never returned to baseline prior to the start of his second seizure. Status epilepticus is defined as ≥5 minutes of continuous seizures, or ≥2 discrete seizures between which there is incomplete recovery of consciousness. Status epilepticus is a life-threatening condition. Causes of seizure are broad and may be congenital, neoplastic, metabolic, or acute intracranial hypertension or mass effect.Initial therapy for acute seizures and possible status epilepticus should include a benzodiazepine, such as lorazepam. Lorazepam 0.1 mg/kg (or a fixed dose of 4mg) should be administered intravenously at a maximum rate of 2 mg/minute, allowing a few minutes (eg, 3 to 5 minutes) to assess its effect before deciding whether additional doses are necessary. The dose of lorazepam should be repeated if the patient is still seizing. There is no definite maximum dose of lorazepam.

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The axillary and subclavian arteries are at increased risk for injury when there is a posterior dislocation of the shoulder. Arterial damage may manifest by occlusion or dissection, and imaging techniques of noninvasive angiography is the most appropriate initial exam

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The increase of group B streptococcal joint infections is associated with the increased prevalence of diabetes and increasing life expectancy.

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The initial test of choice for Zollinger-Ellison syndrome is a fasting serum gastrin (off proton pump inhibitors). The diagnosis is confirmed with a secretin infusion test. It is associated with MEN1.

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The length of treatment for a first time DVT depends on multiple factors; however, the current consensus is at least 3 months of therapy. In the setting of a provoked, especially surgical DVT, it is recommended that anticoagulation be stopped after three months. For patients with unprovoked DVTs, the guidelines recommend at least 3 months of therapy and then a risks/benefits analysis. If the risk of bleeding is low, they recommend no end date for anticoagulation and yearly reevaluation. If there is a high bleeding risk, then 3 months is sufficient for first-time clots as the risk of anticoagulation may outweigh the benefits at that point.

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The most likely diagnosis in this patient is a ruptured distal biceps tendon. The history and physical in this patient is consistent with a rupture of biceps tendon from its distal insertion onto the radial tuberosity. The sudden onset of pain is often associated with a popping noise. Physical exam may show decreased supination and flexion of the elbow. The C5 reflex is tested by tapping the distal biceps tendon with a reflex hammer, and is often absent in patients with a biceps tendon rupture. The biceps muscle is innervated by the musculocutaneous nerve.

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The most likely diagnosis in this patient is migraine headache. These headaches are localized and associated with other symptoms such as sensitivity to light, movement, and sound and nausea or vomiting. Abnormal straining patterns at the sphenobasilar synchondrosis (SBS) and cervical or upper thoracic spine dysfunction are commonly associated with migraines.

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The most likely diagnosis is immune thrombocytopenic purpura (ITP). In this disease anti-platelet antibodies cause platelet destruction leading thrombocytopenia and elevated megakaryocytes in the bone marrow. ITP presents with thrombocytopenia, prolonged bleeding time and splenomegaly in an otherwise healthy patient. Petechiae are the most common skin manifestation of thrombocytopenia

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This patient has Methicillin-Resistant Staphylococcus aureus (MRSA) bacteremia as determined with repeat blood cultures which have remained positive. The likely source for this patient's bacteremia was initially the osteomyelitis/diskitis and epidural abscess, however, the persistance of positive cultures despite appropriate antibiotic therapy and source control is concerning for endocarditis. Endocarditis is diagnosed using the modified Duke Criteria. These criteria are divided into major and minor as well as pathological and clinical criteria. Combinations of major and minor criteria result in either definite endocarditis or possible endocarditis.

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This patient has a left on left sacral torsion. To treat a left on left sacral torsion with an indirect technique, pressure is applied in the direction of ease to the point of balanced ligamentous tension. The right base will be carried anterior and the left inferolateral angle posterior. One technique puts the patient supine with the physician at the patient's left side. The physician places his/her left hand under the sacrum with fingers at the base and palm cupping the apex. The physician applies anterior tension to the right base to rotate the sacrum left on the left oblique access to the point of balanced ligamentous tension. Respiratory phases are tested and the patient holds his/her breath as long as possible in the phase that allows the best ligamentous tension.

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This patient is presenting with signs and symptoms consistent with hypovolemic shock secondary to vomiting, likely as a result of brain metastases. The first step in managing this patient, and any patient with concern for hypovolemia, is resuscitation. This patient's vital signs are unstable and must be addressed. The preferred method of resuscitation is with crystalloid fluids as multiple studies have failed to show a benefit of the use of colloids. After the ABC's have been addressed, then proper workup can be completed.

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This patient is presenting with third-trimester, painless bleeding without contractions or fetal distress. The most likely diagnosis is placenta previa, which occurs due to abnormal implantation of the placenta close to the cervical os. Ultrasound will show the placenta either completely or partially covering the os. Treatment includes cesarean section.

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Type 1 diabetes mellitus (DM-1) is an autoimmune condition and has been associated with an increased risk for other autoimmune conditions. Additionally DM-1 may be part of polyglandular autoimmune syndromes (PAS), which include DM-1 and autoimmune hepatitis. In addition both type 1 DM and autoimmune hepatitis share a common human leukocyte antigen (HLA). Both are strongly associated with the HLA-DR3 and DR4 haplotypes. Some studies suggest that up to 90% to 95% of all children with type 1 DM carry one or both of these haplotypes, while other studies suggest that up to 85% of patients with type 1 autoimmune hepatitis have express these same haplotypes.

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Bottom Line: The classic triad of symptoms in patients with a pheochromocytoma consists of episodic headache, sweating, and tachycardia COMBANK Insight : The 3 characteristics of headaches, palpitations, and diaphoresis (with possible association of hypertension) together are strongly suggestive of a pheochromocytoma. For COMLEX purposes, if you do not see the classic triad, then you can exclude the diagnosis of pheochromocytoma.

true Bottom Line: Twenty-four-hour urinary catecholamine metabolites are used to test for a pheochromocytoma.

Polyarticular juvenile idiopathic arthritis involves greater than four joints and positive rheumatoid factor in some cases. Management is with NSAIDs and DMARDs.

true Juvenile idiopathic arthritis (JIA) can be classified into three categories: systemic, pauciarticular, and polyarticular.Polyarticular JIA is characterized by involvement of greater than 4 joints with a peak age of onset at 2-5 years, with another peak at 10-14 years of age, with females > males affected. Any joint can be affected with hip involvement rare. Rheumatoid factor (RF) is positive in 10-20% of patients greater than age 10 with polyarticular JIA and mild anemia, and mildly elevated erythrocyte sedimentation rate is common. Antinuclear antibody may also be positive in these cases. In addition to increased white blood cell count, erythrocyte sedimentation rate, C-reactive protein, and platelets may be elevated.In order for the diagnosis to be made, the patient must have a daily fever for two weeks in addition to arthritis. Management of polyarticular JIA involves the use of NSAIDs as first-line treatment, but this is unlikely to yield long-term control. Disease-modifying antirheumatic drugs such as methotrexate and sulfasalazine should be added early in the course of treatment. Prognosis is better for RF-seronegative patients as they typically respond better to treatment with NSAIDs alone. In addition, these patients often require screening by ophthalmology as they are at increased risk of developing uveitis

Risk factors for FAS include: Higher maternal age Higher gravidity and parity History of miscarriages and stillbirths Inadequate prenatal care Poor maternal nutrition during pregnancy History of FAS in previous children Substance use, including tobacco Mental health problems, including depression History of physical or sexual abuse or intimate partner violence Social isolation, including living in a rural area during pregnancy Other maternal family members including the mother's intimate partner with substance use at the time of pregnancy Poverty

true Living in an urban area during pregnancy is not a risk factor for FAS. Social isolation, including living in a rural area during pregnancy is a risk factor. In an urban area there are more people and access to resources than in a rural area.

This is a classic description of an imperforate hymen in a newborn, which is the most frequent obstructive anomaly of the female genital tract. Most cases are diagnosed shortly after delivery of the infant by the presence of a bulging vaginal introitus. There is no vaginal bleeding, which may help differentiate it from sarcoma botryoides. The infant is asymptomatic, and the bulging is simply witnessed on exam. The hymen usually ruptures before birth due to degeneration of the central epithelial cells. However, a thin fold of mucous membrane persists around the vaginal introitus.At birth, if an imperforate hymen is present, infants may have a bulging introitus due to mucocolpos from vaginal secretions stimulated by maternal estradiol. If the diagnosis is not made in the newborn period and the hymen remains imperforate, the mucus will be reabsorbed and the child usually remains asymptomatic until menarche. At that time, the adolescent girl may present with a history of cyclic abdominal or pelvic pain and hematocolpos, which may give the hymenal membrane a bluish discoloration. Marked distension of the vagina may also result in back pain, pain with defecation, or difficulties with urination.

true Pelvic ultrasound is an essential diagnostic modality to confirm the diagnosis of imperforate hymen. Pelvic examination under anesthesia can be performed if diagnosis is still unclear following ultrasound.

The Sister Mary Joseph nodule is a skin manifestation as the result of metastasis of a malignant cancer, most commonly originating in the GI tract, with gastric cancer being among the most common.

true Sister Mary Joseph nodules are bulging masses from the umbilicus that can ulcerate and ooze. They most commonly represent metastasis from gastrointestinal cancers, with the most common primary sites being gastric and colon cancers. The sign is associated with a poor prognosis. This condition was named for Sister Mary Joseph, who was a surgical assistant for Dr. William Mayo, who noted the association between paraumbilical nodules observed during skin preparation for surgery and metastatic intra-abdominal cancer confirmed at surgery. Metastasis to the umbilical region is not fully understood, but many theories exist. They occur through a hematogenous spread, lymphatic spread, or even through ligaments of an embryonic origin. Smoking and alcohol consumption are two significant risk factors for GI cancers.

Bottom Line: The best way to reduce the risk of Salmonella infection is by proper hygiene (eg, hand washing) and properly cooking food.COMBANK Insight : Public health questions in this form are rare and usually do not ask about intervention far back in the supply chain. It is worth considering why they would give options for treating workers (eg, typhoid fever). In general, hand washing and proper cooking can greatly reduce the risk of any foodborne illness.

true The best way to reduce the risk of Salmonella infection is by proper hygiene (eg, hand washing) and properly cooking food.Answers A & C: Giving all factory workers antibiotics or giving the source worker antibiotics would be an option for typhoid fever (Salmonella typhi). However, the typical presentation is fever, malaise, diffuse abdominal pain, and constipation (not diarrhea).

Bottom Line: Look for the diagnosis of pseudotumor cerebri in a young obese woman who presents with recurrent morning headaches and evidence of papilledema.

true The patient is presenting with symptoms of idiopathic intracranial hypertension, which is also known as pseudotumor cerebri. This diagnosis is classically seen in an obese female of childbearing age who presents with morning headaches that are recurrent along with nausea and vomiting. Excess vitamin A may be a cause. It can be effectively treated with carbonic anhydrase inhibitor diuretics such as acetazolamide or cerebrospinal fluid shunting.

Bottom Line: A young patient presenting with acidosis, dehydration, and weakness should make you think about DKA.COMBANK Insight : Questions regarding diabetes mellitus are repeatedly seen on COMLEX exams year after year. Cases (such as the one above) may be very general and may leave you guessing. Look for slight clues in the case stems to help you make a correct diagnosis. In this case, noticing the electrolyte disturbances in this patient should have made you suspicious for DKA.

true This is a typical question type that has been known to frequent COMLEX exams. Although one could argue that this is a fairly vague question, it can easily be answered when looking at the clinical scenario. Here is a young patient with hyponatremia and hyperkalemia. This should raise your clinical suspicion for diabetic ketoacidosis (DKA). An immediate fingerstick blood sugar level would probably have been checked on admission in the actual emergency department; however, you were purposely not given that information and should be able to recognize the absence. DKA is defined by the presence of all of the following in a diabetic patient: Hyperglycemia - Blood glucose > 200 mg/dL (11 mmol/L) Metabolic acidosis - Venous pH < 7.3 or serum bicarbonate < 15 mEq/L (15 mmol/L) Ketosis - Presence of ketones in the blood (3 mmol/L beta-hydroxybutyrate) or urine ("moderate or large" urine ketones) DKA is considered a medical emergency and diagnosis should not be delayed. DKA causes electrolyte abnormalities for several reasons. Because hyperglycemia elicits an osmotic effect, extravascular water moves to the intravascular space. Corrected sodium levels can be obtained using the following formula: Na = Measured Sodium + 0.016 * (Glucose - 100). Potassium is probably the most important electrolyte that should be measured in patients with DKA. On presentation, patients are often hyperkalemic because of the acidosis, but actually have a total body potassium deficit. Levels should be checked frequently, as values may drop rapidly with treatment. Electrocardiography can be used to assess cardiac effects if hyperkalemia becomes excessive. Bicarbonate levels can be used in conjunction with the anion gap to assess the degree of acidosis.

Selective serotonin reuptake inhibitors have been shown to be helpful for treating bulimia and general anxiety disorder.

true This patient has signs and symptoms of general anxiety and bulimia. Bulimia nervosa is an eating disorder that results in life-threatening complications. It is characterized by excessive/binge eating with abnormal compensatory behaviors aimed at preventing additional weight gain. These behaviors are displayed either through purging or non-purging techniques such as periods of prolonged fasting, excessive exercise, laxatives, self-induced vomiting, diuretics, or diet pills. In addition, psychiatric comorbidities such as anxiety are common. In this question scenario, the excessive laxative consumption is more likely to be a mechanism for purging rather than for constipation, as the patient claims. Selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (FDA approved) block serotonin reuptake into the presynaptic cell and thus increase its concentration in the synapse. These drugs have been shown to be helpful for bulimia and anxiety and thus they are the best initial choice for this patient. Other treatments include nutritional counseling through a dietician and psychotherapy such as cognitive behavioral therapy.

Lymphogranuloma venereum (LGV) is a sexually transmitted chlamydial infection characterized by painful inguinal lymphadenopathy, fistulas, and granulomas. The recommended medical treatment for LGV involves 1 of the following antibiotic regimens: doxycycline 100 mg PO twice a day for 21 days or erythromycin base 500 mg PO 4 times a day for 21 days. Sex partners who have had contact with the patient within the past 30 days should be evaluated and treated if symptomatic. If no symptoms are present, they should be treated for exposure as follows: doxycycline 100 mg PO twice a day for 7 days or azithromycin 1 g PO as a single dose.

true This patient is presenting with lymphogranuloma venereum (LGV), a sexually transmitted disease caused by invasive serovars L1, L2, L2a, or L3 of Chlamydia trachomatis. LGV is endemic in certain areas of Africa, Southeast Asia, India, the Caribbean, and South America. Characteristic findings include swollen painful inguinal lymph nodes with fistulas, strictures, and granulomatous inflammation. Purulent discharge from the lymph node suggests a fistula. LGV may begin as a self-limited painless genital ulcer that occurs at the contact site 3 to 12 days after infection. Women rarely notice a primary infection because the initial ulceration where the organism penetrates the mucosal layer is often located out of sight in the vaginal wall. In men, fewer than one-third of those infected notice the first signs of LGV. This primary stage heals in a few days. Erythema nodosum occurs in 10% of cases. The secondary stage most often occurs 10 to 30 days later, but can present up to 6 months later. The infection spreads to the lymph nodes through lymphatic drainage pathways. The most frequent presenting clinical manifestation of LGV among males whose primary exposure was genital is unilateral (in two-thirds of cases) lymphadenitis and lymphangitis, often with tender inguinal and/or femoral lymphadenopathy because of the drainage pathway for their likely infected areas. Lymphangitis of the dorsal penis may also occur and resembles a string or cord. If the route was anal sex, the infected person may experience lymphadenitis and lymphangitis, noted above. The patient may instead develop proctitis, inflammation limited to the rectum (the distal 10 to 12 cm) that may be associated with anorectal pain, tenesmus, and rectal discharge; or proctocolitis, inflammation of the colonic mucosa extending to 12 cm above the anus and associated with symptoms of proctitis plus diarrhea or abdominal cramps. In addition, symptoms may include inflammatory involvement of the perirectal or perianal lymphatic tissues. In females, cervicitis, perimetritis, or salpingitis may occur as well as lymphangitis and lymphadenitis in deeper nodes. Because of lymphatic drainage pathways, some patients develop an abdominal mass, which seldom suppurates, and 20% to 30% develop inguinal lymphadenopathy.Systemic signs include fever, decreased appetite, and malaise. Diagnosis is more difficult in women and men who have sex with men (MSM), who may not have the inguinal symptoms. Over the course of the disease, lymph nodes enlarge, as may occur in any infection of the same areas as well. Enlarged nodes are called buboes. Buboes are commonly painful. Nodes commonly become inflamed, with thinning and fixation of the overlying skin. These changes may progress to necrosis, fluctuant and suppurative lymph nodes, abscesses, fistulas, strictures, and sinus tracts. During the infection and when it subsides and healing takes place, fibrosis may occur. This can result in varying degrees of lymphatic obstruction, chronic edema, and strictures. These late stages characterized by fibrosis and edema are also known as the third stage of LGV and are mainly permanent.

Bottom Line: Although uncommon in children, intracranial neoplasms can occur, and alarm signs can be remembered with the mnemonic SNOOPPPPY. In a nonemergent setting, MRI of the brain would be appropriate to avoid unnecessary radiation exposure in a pediatric patient. It is more sensitive and specific than CT. A CT is done if MRI is not available.

true This pediatric patient presents with headaches and alarm symptoms; however, there is nothing emergent in this presentation concerning for an acute issue such as intracranial bleed, which would require a CT of the brain. The slow time-course and classic presentation is more concerning for mass than anything else. The probability of this child having an intracranial mass is increased with multiple red flags including nighttime awakening, positive findings on the neurologic exam, and onset within 6 months. Multiple studies have examined the risk-benefit ratio of neuroimaging and suspected intracranial masses.When assessing a pediatric patient, it is best to risk stratify them and keep in mind the rarity of intracranial masses in a healthy pediatric population. One study of pediatric patients presenting with headaches showed only 0.37% of those with imaging showed significant intracranial pathology. Headaches may precede other associated deficits, and positive neurologic findings on physical exam are strongly associated with intracranial masses. A common mnemonic to guide obtaining further imaging for adults and extrapolated to the pediatric population: SNOOPPPPY.S: systemic symptoms (e.g., fever, altered level of consciousness, anticoagulation therapy, pregnancy, cancer, or HIV infection)N: neurologic signs or symptoms (e.g., papilledema, abnormal cranial nerve function, motor function, cerebellar function, seizure)O: onset recently (between 2 weeks and 2 months or suddenly)O: occipital localization of painP: precipitated by Valsalva maneuverP: positionalP: progressiveP: parent (i.e., lack of family history of headaches)Y: years (i.e., age < 6 years) MRI is the preferred imaging choice for suspected mass lesions if emergent imaging or studies are not required (i.e., suspected bleed, meningitis, etc.) It is more sensitive, specific, and does not carry the risk of radiation exposure, which is very important in children.A study revealed that for high-risk children with headache of < 6 months' duration and other clinical predictors of a brain tumor such as an abnormal neurologic examination, the most effective strategy was MRI (vs CT), with cost-effectiveness ratio of $113 800 per quality-adjusted life year gained compared with no imaging.Gadolinium-based contrast media are recommended for improved imaging quality.

Bottom Line: The lowest rib is treated first for inhalation dysfunction of a group of ribs.COMBANK Insight : Rib dysfunctions are basically always tested on COMLEX exams. It is essential that you understand the concept of muscle energy. Most questions will test your ability to identify the correct rib and your understanding of the actual process of treatment. Don't be fooled by oddly worded answer choices that are actually correct. For example, you may encounter something like: "Patient supine, rib 5 held down in exhalation with palms on the superior surface of the rib." Be able to describe the actual treatment process of these patients when using muscle energy. We promise it will be well worth your while! Decision Analysis

true When presented with a group of ribs in an inhalation position, it is most appropriate to treat the bottom rib first. Ribs 2-5 move mostly using a "pump handle" motion, and somatic dysfunction is described as "inhaled" or "exhaled," based on the motion preference. As these ribs exhibit restricted motion in exhalation, the diagnosis is "inhalation somatic dysfunction of ribs 3-5."

Bleeding disorders, such as hemophilia A, are rare causes of nosebleeds. These patients more often complain of bleeding from their gingival surfaces.

true also Bleeding disorders, such as von Willebrand disease, are rare causes of nosebleeds. These patients more often complain of bleeding from their gingival surfaces.

Anteriorly, at the tip of the right 12th rib, is a classic Chapman's point for the appendix.

true Posteriorly, visceral dysfunction of the appendix can manifest over the transverse process of T11.

------is used to treat warfarin toxicity with active bleeding.

Fresh frozen plasma

----- syndrome may be caused by chloramphenicol. Chloramphenicol works by inhibiting the 50S peptidyl transferase enzyme in bacterial cells. It can be used to treat meningitis, but is rarely used today due to its toxicity potential.

Gray baby

--------can be caused by overconsumption of fish. It presents with diarrhea, constricted visual fields, renal failure, tachycardia, hypertension, peripheral neuropathy, and hyperhidrosis. It can be treated with chelating agents such as succimer, dimercaprol, or penicillamine.

Mercury poisoning

------- are patient-initiated breaths with a pressure limit. The ventilator provides the driving pressure for each breath, which determines the maximal airflow rate. Inspiration is terminated once the inspiratory flow has decreased to a predetermined percentage of its maximal value.

Pressure support breaths

-----is a defense mechanism that allows someone to deal with emotional issues by falsely accusing their own unacceptable thoughts onto someone else. The most common analogy is when a husband accuses his wife of cheating although he is the one that is being unfaithful.

Projection

-----prevents leukotriene synthesis by inhibiting 5-lipoxygenase.

Zileuton

Bottom Line: Examination of the affected side of sciatica may reveal decreased or absent reflexes.

True

Diseases with -----------inheritance include: adult polycystic disease, familial hypercholesterolemia (type IIa), Marfan syndrome, neurofibromatosis (types 1 and 2), von Hippel-Lindau, Huntington disease, familial adenomatous polyposis, and hereditary spherocytosis.

autosomal dominant

Rosacea is a chronic inflammatory disease characterized often by the presence of erythema and flushing of the face, in addition to papules, pustules, and/or rhinophymatous changes (enlargement of the nose). Management involves the use of topical antibiotics such as metronidazole cream with or without oral antibiotics such as doxycycline.

true

Lewy-body dementia is characterized as an atypical parkinsonian syndrome. The classic triad includes dementia, visual hallucinations, and parkinsonian symptoms (cogwheeling, flat affect, resting tremor, etc.). Of note, its first presenting symptom is often REM sleep behavior disorder in which patients lose muscle paralysis during REM sleep and act out their dreams.

true Lewy-body dementia is generally more rapidly progressive.

Injury to the ? is seen more often in the post-menopausal population.

vagina wall

Heroin

---- would cause pupillary constriction, constipation, CNS depression, and respiratory depression.

-----is the second most common organism found in infected bile.

Klebsiella

-----damage can be caused by fluoroquinolone use.

Cartilage

Elevated TIBC is characteristic of iron deficiency anemia.

True

Bleomycin has a strong association with ------

pulmonary fibrosis.

Bottom Line: Obstructing the visual axis in children can result in amblyopia and permanently affect the vision.

true

Bottom Line: Therapeutic endoscopy with variceal ligation is the treatment of choice for patients with bleeding esophageal varices.

true

Medical therapy is tried before any surgical intervention in the case of nasal polyposis.

true

To maintain a healthy pregnancy, women should consume on average about 300 kcal/day beyond nonpregnant energy requirements.

true

Ropy tissue and pallor are associated with chronic conditions and would most likely not be present in this patient.

true note pallor is an unhealthy pale appearancr

Arterial blood gas analysis should be performed in all patients suspected of having salicylate toxicity. A mixed respiratory alkalosis and positive gap metabolic acidosis would support the diagnosis.

true

Arthritis may be part of reactive arthritis (formerly known as Reiter syndrome), which may occur several weeks after a Chlamydia infection.

true

As mentioned earlier, isotonic sodium chloride is not preferred over lactated Ringer's solution because lactated Ringer's has a lower sodium concentration and higher pH.

true

Direct visualization through fiberoptic laryngoscopy (or alternative laryngoscopy) should be used in patients suspected of having damage to the recurrent laryngeal nerve.

true

Dissociation occurs when an individual mentally separates part of his or her consciousness from real-life events. An example would be a woman who has no recollection of being raped.

true

Heparin is a treatment option in acute coronary syndrome, depending on the type. It is used in the treatment of unstable angina and non-ST elevation MI.

true

Life-saving care, including blood transfusions, should not be denied to a minor in an emergency situation despite parental objection.

true

Measles is caused by paramyxovirus and is characterized by cough, coryza, and conjunctivitis. Koplik spots are also specific to measles, along with an erythematous, maculopapular rash that spreads from the head toward the feet.

true

Posterior cruciate ligament (PCL) tears result from direct trauma to the upper anterior tibia while the knee is flexed. This is most commonly seen in a dashboard injury or a baseball player sliding into a catcher.

true

A 20-year-old G1P1 presents to the emergency room after a sexual assault. Multiple bruises are noted on the patient's neck, wrists, breasts, and thighs. Speculum exam will most likely reveal trauma to the - fossa navicularis - hymen - labia minor -Vaginal wall injury -posterior fourchette

----- is the most common site of vaginal injury in a sexual assault victim.

Viral conjunctivitis

------ may also present with red, watery eyes. Watery exudates and erythematous injection of the conjunctiva will be present on physical exam in addition to preauricular adenopathy. In addition, there is often crusting and matting of the eyelashes upon awakening in the mornings. It is usually caused by adenovirus and treatment is supportive.

Bacterial conjunctivitis

-------- may present with painful, watery, red eyes. Physical exam may show a purulent exudate, and patients typically complain of matted eyelashes upon awakening. It is usually caused by Staphylococcus aureus, but may also be caused by Streptococcus pneumoniae or Haemophilus influenzae. Treatment consists of gatifloxacin ophthalmic solution.

Turner syndrome Ullrich-Turner syndrome

---- is associated with high arched palate and increased carrying angle. is associated with increased paternal age. It is due to a mutation in fibroblast growth factor. Patients present with short limbs but typically have normal head and trunk size. is associated with high arched palate and increased carrying angle of the arm. More classic signs include a webbed neck (cystic hygroma), broad "shield" chest, and streak ovaries. Turner syndrome is also associated with coarctation of the aorta. Turner syndrome is a genetic disorder only affecting females and is characterized by the 45, XO genotype, with an incidence of 1:10,000. A karyotype is diagnostic. Workup should include a baseline echocardiogram, renal ultrasound, blood pressure, and hearing screen. The prognosis is good and patients can expect a normal lifespan; however, these patients are infertile.

Down syndrome

----------is typically associated with short stature; however, is not typically associated with a high arched palate or cubitus valgus (increased carrying angle). is associated with endocardial cushion defects (ventricular septal defect, atrial septal defect, tetralogy of Fallot, and patent ductus arteriosus).

Allergic conjunctivitis

----------usually presents with red, watery, itchy eyes. Treatment is with antihistamines. The most likely diagnosis in this patient is allergic conjunctivitis. Allergic conjunctivitis is a common cause of red, watery eyes. It usually presents in patients with a history of allergies or atopic dermatitis. It can be associated with seasonal high pollen counts, animals, mites, dust, and other causes of allergies. Patients complain of episodes of itchy, watery eyes that may be alleviated with antihistamines.

T11-L2

------provides sympathetic innervation to the lower extremities. L3-5 does not provide sympathetic innervation to any structures. Remember this and you will usually be able to rule out an answer choice right away.

Williams syndrome

----is associated with "elfin" facial appearance and extreme friendliness but poor social skills. also associated with supravalvular aortic stenosis.

Marfan syndrome

----is associated with a high arched palate, but patients are usually tall with a marfanoid habitus (long limbs, arachnodactyly, and hyperlaxity). is associated with mitral valve prolapse, aortic root dilatation, and aortic dissection.

LSD

----would most likely cause anxiety, depression, pupillary dilation, and flashbacks.

Bottom Line: Hemodialysis should be performed in patients with methanol poisoning who meet the following criteria: 1) Ingestion of methanol volumes greater than 30 mL 2) Serum methanol levels of 20 mg/dL or greater 3) Development of visual changes 4) Lack of acidotic improvement despite multiple sodium bicarbonate infusions COMBANK Insight : Indications for hemodialysis also include: hyperkalemia refractory to medical therapy, uremic pericarditis and ESRD.

--Ipecac-induced emesis is contraindicated due to the risk of rapid loss of consciousness. --Gastric lavage would need to be performed immediately after ingestion to be beneficial --Gastric decontamination is unlikely to be beneficial due to the rapid and complete absorption of methanol from the gut. --It is doubtful that activated charcoal would have the ability to absorb such large amounts of methanol but may be useful if a co-ingestant is suspected.

During moderate (middle time) severity of aspirin toxicity what are some signs of toxicity? 500-700mg/l

-All of the mild symptoms of burning, in the mouth, lethargy, nausea/vomiting, tinnitus, dizziness as well as additional things of tachypnea, hyperpurexia, sweating, dehydration, loss of coordination, restlessness

Your patient returns several weeks later complaining of a red bulge on his medial buttocks which has increased in pain over the last 24 hours. He notes progressive pain and fevers. He has a temp of 101°F and a WBC of 18x103/mcL (reference range: 4.8-10.8 x 103/mcL) with otherwise normal vital signs. On exam a large, 5 cm, fluctuant, tender mass is noted within his left gluteal cleft. What is the most likely diagnosis?

1. Perianal abscess Bottom Line: Remember fevers chills and a fluctuant palpable mass is indicative of an abscess. Most infections in and around the anus which result in abscess formation are due to infection of the anal crypts by resident bacteria including gram negatives from the gut and gram positives from the adjacent skin. Around 10% of anal abscesses are due to other conditions such as Crohn's disease, malignancy, STI, hidradenitis, trauma, or immune suppression. Abscesses are relatively easy to recognize by being large, fluctuant, and having accompanying signs of systemic infection. Ultrasound of the area will reveal a hypoechoic, fluid-filled pocket. All abscesses should be evaluated for incision and drainage by a surgical team and complex abscesses in the anal region which can involve the rectal fascia or other planes within the pelvis will need operative management under anesthesia. Abscesses in this area often result in fistula tracts which may need to be excised. Extensive surgical intervention in this area does come with a risk of fecal incontinence if the external sphincter is damaged. The external sphincter can also be compromised by severe, untreated infection, so abscesses in this area should be seen by a surgical consultant (or if small and uncomplicated, drained in the ED) as soon as possible.

Patients with acute pancreatitis lose a large amount of fluids to third spacing into the retroperitoneum and intra-abdominal area. Accordingly, they require prompt intravenous hydration within the first 24 hours. There is no universal consensus definitively favoring one type of fluid over another type; both crystalloids and colloids are used. Resuscitation should be sufficient to maintain hemodynamic stability. This usually involves administration of several liters of fluid as a bolus, followed by continuous infusion at a rate of -----

250 to 500 mL/h. Resuscitation should be sufficient to maintain hemodynamic stability. This usually involves the administration of several liters of fluid as a bolus, followed by continuous infusion at a rate of 250 to 500 mL/h. Central venous pressure, pulmonary artery wedge pressure, and urine output (>0.5 mL/kg/h) can be followed up as markers of adequate hydration. Careful attention should be paid to signs of overhydration, such as pulmonary edema causing hypoxia. Analgesics are administered for pain relief. Antibiotics are generally not indicated. If ultrasonograms show evidence of gallstones and if the cause of pancreatitis is believed to be biliary, a cholecystectomy should be performed during the same hospital admission. Feeding should be introduced enterally as the patient's anorexia and pain resolve. Patients can be initiated on a low-fat diet initially and need not invariably start their dietary advancement using a clear liquid diet.

-----is the belief that people are all good or all bad, with no middle ground. This is commonly seen in patients with borderline personality disorder.

: Splitting

cdm cases The incoherent geriatric patient is a common presentation. The differential for this patient is broad and, as such, an algorithmic approach is necessary to investigate the most critical and most common underlying diagnoses. As with assessing any new emergently presenting patient, evaluation should initially include obtaining a pertinent history and complete physical exam to allow the provider to hone in on the most likely causes of the patients altered mental status and avoid unnecessary tests, which is important from both a time and a cost standpoints. Still, in this case, there are certain universal tests which should be obtained and started concurrently. These include establishing IV access and treatment of her hypotension with IV fluids; general labs are already ordered CMP and CBC to look for electrolyte disturbances, renal failure, anemia, or signs of infection, but additionally one should obtain a fingerstick blood glucose immediately (given her history of diabetes), as well as lactic acid, venous or arterial blood gas and creatine kinase (CK) levels given the possibility of acidosis, rhabdomyolysis and hypotension; lastly a cardiac assessment with an electrocardiogram should be obtained and given likely atrial fibrillation with rapid ventricular rate, a troponin level could be considered. This patient does not have risk factors for drugs of abuse, but a urine drug screen could also be considered when a urinalysis is obtained. Be wary, while many geriatric patients may have pyuria, there is a large portion of asymptomatic pyuria/bacteriuria in the geriatric population and not every confused elderly patient has a urinary tract infection. Because she has had a fall and is incoherent with an uncertain down time while on anticoagulants, a CT head should be obtained and strong consideration can be made for a CT cervical spine.

A confused geriatric patient who presents with a fall and abnormal vitals should have a broad initial workup, including CT head, basic laboratories, lactate, CK, EKG, and fingerstick glucose. The COMLEX loves to test the ability to develop a broad differential without wasting time or resources. While this sounds conflicting, things, like obtaining a thorough H&P, basic labs, and EKG, and establishing IV access for fluid administration, are relatively cheap and can lead to the diagnosis or at least guide the clinician in the next step in the majority of cases.

B. reassurance and follow-up for this problem after 1 year of age This patient is presenting with an umbilical hernia. Hernias are caused by failed closure or weakness in the umbilical ring and appear as soft masses covered by skin that protrude with increased intra-abdominal pressure and easily reduce. A higher incidence is noted in black and low-birth-weight children. Size can be from <1 cm to 5 cm. Typically, they resolve before 1 year of age. In this situation, reassurance and follow-up are the best course of action. Umbilical hernias in children will most likely close spontaneously within 1 year and rarely strangulate. The best course of action is reassurance with return precautions. If complications develop, surgical intervention may be warranted. Surgery is not considered unless the hernia persists to age 4 to 5 years or causes symptoms, strangulation occurs, or it increases in size after 1 to 2 years of age.

A mother brings her 1-month-old male son to the primary care clinic because she is concerned about a palpable mass in his abdomen. He was delivered at home and has received no further care, but she states his birth was uneventful. Upon physical examination, a mass is noted coming from the umbilical area, as shown in the exhibit. When the child cries, it protrudes more. What is the next step in the management of this patient? A. nasogastric tube decompression, antibiotics, and supportive care B. reassurance and follow-up for this problem after 1 year of age C. strapping the mass to prevent protrusion D. surgical consult E. wrapping the mass in sterile dressings

Signs of sepsis, flank pain, and the symptoms of a urinary tract infection is diagnostic of pyelonephritis. what imaging would you get?

A non-contrast CT of the abdomen and pelvis or a renal ultrasound can be used to rule out structural renal abnormalities and should be the first tests considered when assessing a patient with new-onset pyelonephritis and concern for possible infected renal stones. Cystoscopy will only show bladder anatomy/ pathology and is not necessary for the workup of urinary tract infection or pyelonephritis. In fact, most urologists would prefer to avoid instrumentation of the bladder or urinary tract during an active infection, if possible, as this can cause disruption of the mucosa and there is concern for the developement of bacteremia.

Therapy for hemorrhoids is generally started with conservative interventions as listed below. More invasive therapies can be tried for large internal hemorrhoids (as these can sometimes exacerbate the more painful external hemorrhoids) and include rubber-band ligation, sclerotherapy, and surgical hemorrhoidectomy. Internal hemorrhoids can be graded I-IV depending on their size and location. These grades can assist in management decisions. Grade I have bleeding only, without prolapse. Grade II prolapse with defecation but reduce on their own. Grade III prolapse with defecation and do not reduce on their own, but can be manually reduced. Grade IV hemorrhoids are prolapsed, incarcerated, and cannot be manually reduced. Surgical intervention is generally reserved for grade IV internal hemorrhoids.Improving hydration will help prevent constipation, which may improve the patient's symptoms. Water intake should be increased with fiber intake to increase stool bulk and prevent hardening.

A tear in the mucosa lining the anus is called an anal fissure and can be a significant source of pain and distress. They are felt to be caused by straining with defecation and the passage of large, hard stools which rips the anal mucosa. Fissures can cause bleeding and are generally associated with bright red blood on the toilet paper with wiping. They can be visualized on an external exam if they are large enough or with an anoscope. They usually heal relatively rapidly without long-term issues. The most common location of anal tears is the posterior midline. Conservative interventions for anal fissures is generally the same as those for hemorrhoids: increasing water and fiber intake, warm water soaks and limiting straining during defecation. Because there is some increased tone of the anal sphincter, topical nifedipine can sometimes help to reduce pain and spasm and possibly improve healing. Some patients go on to have chronic anal fissures which could require surgical intervention.

------ test is confirmatory for Helicobacter pylori in the setting of peptic ulcer disease, but would have no use in this scenario.

A urea breath

------- is a volume-cycled mode of ventilation. It works by setting a fixed tidal volume (VT) that the ventilator will deliver at set intervals of time or when the patient initiates a breath. The VT delivered by the ventilator in AC always will be the same regardless of compliance, peak, or plateau pressures in the lungs. This setting allows the patient to over-breath the ventilator but must receive the set amount of breaths based on the set minute ventilation.

Assist-control ventilation

A 47-year-old nurse who has recovered from a past infection with hepatitis B virus after suffering from a needle-stick injury early in her career. A. Anti-HBs + anti HBc (IgG) B. Anti-HBc (IgM) only C. Anti-HBs only D. HBsAg + anti-HBs E. HBsAg + HBeAg + anti-HBc (IgM)

A. Anti-HBs + anti HBc (IgG) B. Isolated antibodies to the core antigen (with no other positive serology) is the hallmark of the window period. C. The presence of antibodies to the surface antigen but not the core antigen is the hallmark of a successful vaccination. D-This serology is consistent with acute, active infection. IgM antibodies to the core antigen indicate that the infection is acute. The absence of other antibodies indicates that the infection is active and transmissible. E-This serology is consistent with acute, active infection. IgM antibodies to the core antigen indicate that the infection is acute. The absence of other antibodies indicates that the infection is active and transmissible.

A 39-year-old female presents to the emergency department with abnormal bleeding from the uterus. After a thorough workup, the patient is ultimately diagnosed with dysfunctional uterine bleeding (DUB). The patient is sent home on conjugated equine estrogen and told to return if her bleeding does not abate. After 72 hours, she continues to have profuse bleeding and returns to the emergency department. Her vital signs are as follows: blood pressure of 106/72 mm Hg, pulse of 105/min, respiratory rate of 14/min, and temperature of 37.3°C (99.1°F). The most appropriate next step in management is A. Dilatation and Curettage B. Endometrial Ablation C. Observation alone D. Salpingoophorectomy E. Total Abdominal hysterectomy

A. Dilatation and Curettage Bottom Line: Bleeding might be controlled acutely with high-dose estrogen for a short period of time. Several hours are required to induce mitotic activity, so most regimens require 48 hours of therapy before continued bleeding is ruled a treatment failure. Estrogen therapy only controls bleeding acutely and does not treat the underlying cause. Appropriate long-term therapy can be administered once the acute episode has passed. If flow fails to abate in 24 to 48 hours, dilatation and curettage (D&C) should be performed in all patients over the age of 35 who are diagnosed with dysfunctional uterine bleeding (DUB) to rule out endometrial cancer. Be familiar with the new American College of Obstetricians and Gynecologists treatment guidelines for abnormal uterine bleeding for the COMLEX Level 3.

A 66-year-old male with a past medical history of hypertension, diabetes mellitus, and atrial fibrillation presents to the emergency department complaining of sudden-onset abdominal pain. The patient states the pain is around his umbilicus. It is rated at 10/10 and described as constant, with no radiation. The patient had an episode of vomiting prior to presentation. Vital signs reveal a respiratory rate of 21/min, heart rate of 120/min, and blood pressure of 80/40 mmHg. Physical exam is notable for lack of peritoneal signs or specific point tenderness. Rectal exam shows stool with flecks of blood. Question 1 of 3 in this set What is the most likely diagnosis? A. acute mesenteric ischemia B. angiodysplasia C. Budd-Chiari syndrome D. sigmoid volvulus E. small bowel obstruction

A. acute mesenteric ischemia The most likely diagnosis, in this case, is acute mesenteric ischemia secondary to cardiac embolus in a patient with atrial fibrillation.Acute mesenteric ischemia is a form of ischemic bowel. It is described as severe periumbilical abdominal pain that is usually disproportionate to the physical exam. The physical exam will typically present with no or minimal findings despite severe pain. Patients generally complain of nausea, vomiting, pain, and occasionally blood per rectum. Laboratory abnormalities include an elevated D-dimer and, if intestinal necrosis has already begun, an elevated serum lactate level with a metabolic acidosis. Compromised blood flow to the bowels may be completely or only partially occlusive. The most common cause (50%) of acute mesenteric ischemia is arterial embolism, usually from a cardiac source, with thrombosis of the mesenteric arteries (15% to 25%) being the second most common cause. The final common cause of acute mesenteric ischemia is acute thrombosis of the mesenteric veins, which prevents drainage. Acute mesenteric ischemia is an emergency and should be contrasted with chronic mesenteric ischemia, which is more similar to stable angina. It is generally caused by narrowing of the mesenteric vessels due to atherosclerotic disease and commonly presents with pain after eating. It is not a surgical emergency unless it progresses to acute ischemia with complete mesenteric obstruction due to thrombosis. The first-line treatment for mesenteric ischemia is IV fluids, nasogastric tube, and broad-spectrum antibiotics. The most appropriate initial management, in this case, is to start IV fluid resuscitation and broad-spectrum antibiotics, place a nasogastric (NG) tube, and consider further management with either a CT scan or angiography if the patient stabilizes or movement to the operating room if the patient remains unstable. At the very least, the first step in an unstable patient is to administer fluids in an attempt to improve the blood pressure. Be careful when you are assessing what the question is asking you. Although this patient may eventually require a laparotomy, this would not be the first step in the management of this patient. The mortality rate for acute mesenteric ischemia approaches 70%. Once bowel wall infarction occurs, the mortality rate rises to 90%. Even with treatment, 50% of patients may die.

ECG shows a S1Q3T3 pattern, so a CT angiography for pulmonary embolism protocol is ordered and shows a right-sided, segmental pulmonary embolism without evidence of heart strain. Ultrasound with Doppler of bilateral lower extremity is negative for deep vein thrombosis. His troponin I and B-type natriuretic peptide levels are both normal. What is the most appropriate next step in the management of this patient? A. administer the first dose of anticoagulation in the emergency department and discharge on oral anticoagulants B. administer tissue plasminogen activator C. inpatient management with heparin drip in the intensive care unit and consult to interventional radiology for thrombolysis D. get a bedside echocardiogram to rule out right ventricular strain E. inpatient management with heparin drip on the medical floor

A. administer the first dose of anticoagulation in the emergency department and discharge on oral anticoagulants

A 65-year-old male returns to his primary care physician after being discharged from the hospital approximately two weeks prior, following an acute myocardial infarction. He reveals that he has recently been experiencing symptoms of fever and some chest pain. Review of systems reveals no associated shortness of breath. Upon physical examination, the lungs are clear to auscultation bilaterally and cardiac auscultation reveals a friction rub. An electrocardiogram is obtained, which shows no evidence of further cardiac pathology. The most effective therapy for this patient is: A. administration and treatment with non-steroidal inflammatory medication B. administration and treatment with oral antibiotics C. administration of sublingual nitroglycerin D. initiation of an anti-anxiety agent E. intravenous heparin

A. administration and treatment with non-steroidal inflammatory medication The history and physical examination in this patient with a recent myocardial infarction (MI) is consistent with post-cardiac injury syndrome (also known as Dressler syndrome, or post-myocardial infarction syndrome). This generally benign, self-limited syndrome typically presents with autoimmune pleuritis, pneumonitis, or pericarditis characterized by fever and pleuritic chest pain, with onset up to six weeks post-cardiac injury. This syndrome is thought to occur secondary to the presence of blood in the pericardial cavity, which occurs following cardiac surgery, cardiac trauma, or MI. The most effective therapy for this condition is treatment with a nonsteroidal anti-inflammatory agent (NSAID). Glucocorticoids are also used but are considered a second-line therapy. Prophylactic therapy with colchicine has been shown to significantly reduce the incidence of post-cardiac injury syndrome following cardiac surgery; however, it is not recommended.

A 25-year-old G1P0 female presents for her level II anatomy ultrasound at 19 3/7 weeks of gestation. During the ultrasound, a male fetus is seen. The fetus is in cephalic presentation with a fundal grade I placenta. All anatomy is visualized and found to be normal except large, bilateral, polycystic kidneys. The ultrasound finding most likely to be present in association with this disease is A. amniotic fluid index of 1.2 cm B. banana sign C. distended urinary bladder D. echogenic intracardiac focus E. large stomach bubble

A. amniotic fluid index of 1.2 cm The predominant ultrasound feature of autosomal recessive polycystic kidney disease (ARPKD) is uniform, massive enlargement of the kidneys bilaterally (see image). The kidneys have poor function and produce little to no urine. As such, the most common finding associated with ARPKD is oligohydramnios. This is defined as an amniotic fluid index of ≤5 cm. In ARPKD, the oligohydramnios is usually severe. With oligohydramnios and ARPKD diagnosed at this early gestation, fetal and neonatal outcomes are poor secondary to high likelihood of pulmonary hypoplasia. No intrauterine treatment is available.

A 19-year-old college student presents to her primary care physician after experiencing palpitations and fainting in class. History reveals that she is a very picky eater and will only eat certain foods. She prefers to eat alone as she likes to carefully prepare each meal a certain way. She also admits that occasionally she eats too much, which results in vomiting. This occurs approximately 5 times per week after eating. She denies symptoms of gastroesophageal reflux disease or dyspepsia and says that she has done it ever since she was in middle school because she doesn't like the way that she looks when she is "heavy." She states that she is a very dedicated athlete and follows her exercise regimen very strictly, making sure to run at least 3 miles every day no matter how she is feeling or what the weather is outside. Physical exam reveals dry mucous membranes, pallor, and painless bilateral enlargement of the parotid glands. Her height is 165 cm (5 ft, 5 in), and her weight is 41.7 kg (92 lb). Body mass index is 15.3. Her last menstrual cycle was 5 months ago, and testing for human chorionic gonadotropin is negative. Which of the following is the most likely diagnosis? A. anorexia nervosa B. body dysmorphic disorder C. bulimia nervosa D. bulimia nervosa with anorexic features

A. anorexia nervosa Given this patient's low weight (body mass index of 15.3) and lack of binging, she should be diagnosed as having anorexia nervosa. A Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnosis of anorexia nervosa requires each of the following criteria:- Restriction of energy intake that leads to a low body weight, given the patient's age, sex, developmental trajectory, and physical health- Intense fear of gaining weight or becoming fat, or persistent behavior that prevents weight gain, despite being underweight- Distorted perception of body weight and shape, undue influence of weight and shape on self-worth, or denial of the medical seriousness of one's low body weightThe disorder, which usually begins in young people around the time of puberty, involves extreme weight loss that is less than what is considered minimally normal. Many people with the disorder look emaciated but are convinced they are overweight. Sometimes they must be hospitalized to prevent starvation. One of the most frightening aspects of the disorder is that people with anorexia continue to think they are overweight even when they are bone thin. The individual usually experiences an intense and overwhelming fear of gaining weight or becoming fat. This fear is regardless of the person's actual weight and will often continue even when the person is near death from starvation. Individuals suffering from this disorder believe that their body weight, shape, and size are directly related to how good they feel about themselves and their worth as human beings. Persons with this disorder often deny the seriousness of their condition, which is one of the primary diagnostic criteria.Associated features of anorexia include relentless pursuit of thinness, obsessional preoccupation with food, fear of certain foods, restricted repertoire of foods, preference for low-calorie foods, overestimating number of calories consumed, overusing condiments and/or artificially sweetened products, food-related rituals, concerns about eating in public, social withdrawal, exercise-related ritual, restlessness or hyperactivity, limited insight into or denial of core clinical features, resistance to treatment and weight gain, inhibited expression and dysregulation of emotions, feelings of ineffectiveness, poor sleep, low libido, dysphoria, inflexible thinking, perfectionism, need to control one's environment, and behavioral rigidity.

A 17-year-old female, G1P0, at 37 weeks gestation presents to the Emergency Department with vaginal bleeding. The patient states the bleeding started one hour ago. She has used two pads in the last hour. She also describes an intense pelvic pain that radiates into her back. Her vital signs are within normal limits. The next step in management is A. begin fetal monitoring B. observe for 24 hours C. pelvic examination D. type and screen for blood products E. emergent caesarean section

A. begin fetal monitoring The patient has painful vaginal bleeding in the 3rd trimester. The most likely diagnosis is placental abruption. The bleeding results from placental separation from the uterus. Risk factors include hypertension, trauma, cocaine use, or uterine distention. The most important initial step is to evaluate maternal and fetal status (which reflects the severity of the abruption). An unstable mother or non-reassuring fetal status indicates a severe abruption and the need for more aggressive intervention. In cases of mild abruption or premature infant, management is with hospitalization, fetal monitoring, type and cross, and bed rest. When you have a term or near term pregnancy, a trial of labor and plan for vaginal delivery is recommended if the fetal monitoring is reassuring and mother is hemodynamically stable. In severe cases, first, assess the ABC's, obtain type and cross, and send for immediate delivery. These patients need an initial type and screen for possible blood transfusion and to determine the Rh status of the mother.

A 69-year-old man presents with an acute onset of worsening back pain as well as numbness and tingling in both of his feet after falling while mowing the lawn. He reports that over the past two days he has had worsening urinary frequency and suprapubic pain and thought maybe he had a urinary tract infection but didn't have time to go to his doctor. He denies fever, chills, nausea, or vomiting. History reveals type 2 diabetes mellitus and a recent hemoglobin A1c of 12 (reference range: 4.2-5.9%). The patient currently takes insulin glargine 40 units twice daily, insulin lispro 15 units three times daily with meals, and a sliding scale to cover. Physical exam reveals decreased sensation at the feet, inner thighs, groin, and 0/4 Achilles and patellar reflexes bilaterally. His strength is reduced in both legs with 0/5 strength in his dorsiflexors and plantarflexors and 4/5 strength in his left hip flexors and 2/5 strength in his right hip flexors. His laboratories are notable for a normal serum glucose and a urinalysis without blood, protein, or white cells. An ultrasound performed in the emergency department shows significant urinary retention. What is the most likely diagnosis? A. cauda equina syndrome B. Creutzfeldt-Jakob disease C. diabetic neuropathy D. Guillain-Barré syndrome E. multiple myeloma

A. cauda equina syndrome Answer C: Diabetic neuropathy starts distally with loss of sensation and progresses over months to years. Loss of sphincter tone is not common in diabetic neuropathy. It can be treated with medications such as gabapentin.

A. chemical reactive conjunctivitis Newborn conjunctivitis that occurs within the first 24 hours of life is chemical reactive conjunctivitis. Timing is important in regard to newborn conjunctivitis. --Congenital cataracts present as an opacity in the lenses and can lead to blindness. There is a wide range of causes of congenital cataract, but given the description of bilateral reddened conjunctiva in the question stem, the answer is conjunctivitis. --Conjunctivitis occurring 2 to 5 days after delivery is likely caused by gonorrhea. --Conjunctivitis occurring 5 to 14 days after delivery is likely inclusive or chlamydial conjunctivitis. Prevention of neonatal conjunctivitis is accomplished with routine use of silver nitrate, erythromycin, and tetracycline eye drops immediately after delivery. --Strabismus is a deviation of gaze and often presents in children. It can be caused by a variety of cranial nerve issues but does not cause the clinical scenario described in this case. --Neonatal conjunctivitis that begins within the first 24 hours of life is a chemical reaction related to silver nitrate, erythromycin, and tetracycline eye drops.

A 41-year-old female presents to the emergency department with a 3-day history of intractable nausea and vomiting. The patient reports several similar episodes of this over the past 3 years. The latest episode is accompanied by severe mid-epigastric pain, and the patient reports a yellowing of her skin. She reports becoming increasingly intolerable to fatty foods during this time as well. Initial evaluation includes an abdominal ultrasound that reveals a dilated common bile duct with a thickened gallbladder wall and several stones noted within the gallbladder. What is the most likely diagnosis causing this patient's current symptoms? A. choledocolithiasis B. cholelithiasis C. gastritis D. peptic ulcer disease E. small bowel obstruction

A. choledocolithiasis This patient is suffering from choledocholithiasis. A gallstone has passed from the gall bladder to the common bile duct and being lodged in the duct is causing pancreatitis secondary to downstream obstruction of pancreatic material. (Remember the two most common causes of pancreatitis are alcohol and gallstones.) In this case, the patient's pancreatitis may have been prevented with a cholecystectomy early on in her disease. It is important to investigate suspected cholelithiasis and treat it early.

A 30-year-old male is hospitalized sustaining severe burns over 30% of his body. Despite being previously healthy during his hospitalization, he has required up to 20 units of basal insulin daily plus a medium-dose sliding scale. He is not on systemic corticosteroid therapy. The patient likely has a deficiency of A. chromium B. copper C. iodine D. selenium E. zinc

A. chromium Bottom Line: Chromium deficiency has been associated with glucose intolerance and catabolic state increase requirements. Chromium is a trace dietary mineral found in multiple fruits, vegetables, processed meats, and fortified cereals and grains. Absorption is predominately in the small bowel after which it is largely complexed with both albumin and transferrin. Chromium deficiency is infrequently encountered but primarily occurs in the setting of ill patients with increased catabolism and subsequent metabolic demands. A classic example is the burn patient. Other instances where chromium deficiency has occurred include defects of absorption, such as short bowel syndrome or inadequate intake, including with the use of parenteral nutrition or severe malnutrition.Clinically, chromium deficiency is characterized by glucose intolerance and lower levels of chromium have been demonstrated in patients with type 2 diabetes. Although the exact mechanism is uncertain, some attention has been directed toward an oligopeptide termed Apo low-molecular-weight chromium-binding peptide (Apo-chromoduline). This has a potentiating role on insulin-sensitive cells by direct binding of the insulin receptor. Despite this classic association, supplementation with chromium in patients with diabetes is controversial.

On cardiac evaluation, a systolic murmur is auscultated. A murmur that does what would be an indication for an echocardiogram before clearance for sports? A. decreases in intensity with squatting from a standing position B. decreases in intensity with standing from a squatting position C. decreases in intensity with Valsalva D. increases in intensity with laying supine E. increases in intensity with patient laying supine and examiner passively raising legs

A. decreases in intensity with squatting from a standing position When the patient squats from a standing position, the preload is increased and the murmur intensity decreases. Bottom Line: Anything that increases preload will decrease the intensity of the murmur in hypertrophic cardiomyopathy.---such as beta blockers calcium channel blockers to slow the heart rate. Septal myectomy and alcohol ablation of the septum are reserved for patients with severe disease.

A 55-year-old male complains of difficulty walking. Physical exam reveals a wide-based gait with bilateral loss of proprioception and vibratory sense in the lower extremities. He recalls having "some sexually transmitted disease" when he was in his 20s; however, he states that he refused treatment at that time. Which of the following is associated with the most likely diagnosis? A. dilated thoracic aorta B. rash involving his trunk C. ring-enhancing lesions on head CT D. stiff, painful joints E. systolic murmur that radiates to the carotids

A. dilated thoracic aorta The most likely diagnosis is tertiary syphilis. This occurs years after an untreated primary infection. Treatment with penicillin during the primary and secondary phases prevents progression to the tertiary stage. His neurologic symptoms are due to demyelination of the posterior columns (tabes dorsalis). Dilated saccular aneurysm of the thoracic aorta can also be found in patients with this disease. Typically, the maculopapular rash associated with syphilis is seen on the palms and soles. Also, it is present during secondary syphilis and not in tertiary syphilis, which is the condition that this patient is presenting with. A systolic murmur that radiates to the carotids describes the murmur of aortic stenosis. Tertiary syphilis is associated with aortic regurgitation, not stenosis.

A 16-year-old male presents to his primary care physician for a sports physical. His past medical history is significant for a tonsillectomy at the age of 5 and occasional seasonal allergies. He does not take any medications. Both the patient and his mother state that he is in good health, and he has no acute complaints. His blood pressure is 118/72 mmHg, pulse is 105/min, temperature is 36.6°C (97.9°F), and oxygen saturation is 99% on room air. Physical examination is unremarkable. Routine electrocardiogram is performed and reveals a short PR interval with wide and slurred QRS complex. The most appropriate next step in management is A. educate the patient and arrange follow-up with cardiologist B. radiofrequency ablation C. start on digitalis D. start on metoprolol E. start on procainamide

A. educate the patient and arrange follow-up with cardiologist

A mother brings in her 2-year-old to the pediatrician with symptoms of recurrent nosebleeds. A chart review shows no history of bleeding disorders. A physical examination is unremarkable. The physician attempts the vault hold to address any membranous tension within the cranium, but there is no significant dysfunction detected. Given the most likely cause, the most appropriate next step in management is A. home humidified air B. intranasal phenylephrine C. posterior packing D. silver nitrate sticks E. surgical artery ligation

A. home humidified air The most common causes of epistaxis include trauma and dry mucosa. The presented scenario implies that there is no current bleeding; thus, conservative measures should be used first. Conservative management includes humidified air, nasal saline sprays, and local application of petroleum ointment. If those measures fail, intranasal phenylephrine may be attempted. If medical therapy fails, nasal packing or cauterization with silver nitrate is the next step. Surgical artery ligation is the final step in management when other options have failed. Bottom Line: In children with recurrent episodes of epistaxis and no active bleed, conservative measures, such as home humidified air, are recommended. Conservative management includes humidified air, nasal saline sprays, and local application of petroleum ointment. If those measures fail, intranasal phenylephrine may be attempted. If medical therapy fails, nasal packing or cauterization with silver nitrate is the next step. Surgical artery ligation is the final step in management when other noninvasive options have failed.

Which of the following deficits would be expected with injury to the posterior interosseous nerve? A. inability to extend the thumb interphalangeal joint B. inability to flex the thumb interphalangeal joint C. inability to radially deviate the radiocarpal joint D. loss of sensation over the dorsal aspect of the little finger E. loss of sensation over the palmar aspect of the thumb

A. inability to extend the thumb interphalangeal joint

A 32-year-old female, G2P1001 at 39 weeks gestation, with a history of Ehlers-Danlos syndrome is brought to the hospital in active labor. She states that she has had a previous cesarean section at a small hospital in Mexico. The most appropriate method to monitor for uterine rupture is A. internal fetal monitoring B. serial abdominal radiographs C. serial history and physical examination D. serial scalp pH monitoring E. transrectal ultrasound

A. internal fetal monitoring Non-reassuring fetal heart rate patterns are suggestive of impending or actual uterine rupture. This patient has 2 risk factors for uterine rupture: previous cesarean section and a connective tissue disorder. Internal fetal monitoring is more accurate than serial physical exams, and is preferred over scalp monitoring. Complications from uterine rupture include hemorrhage and fetal compromise. This patient should undergo repeat cesarean section, as vaginal birth after cesarean section (VBAC) is considered high risk in this patient. Answer C: Serial history and physical examination are used during standard prenatal care. Although a Leopold exam showing approximate fetal head presentation is helpful, internal fetal monitoring is more accurate.

A 67-year-old diabetic male presents with severe ear and sinus pain, headache, hearing loss, and nausea. He also reports severe pain with chewing. His temperature is 38.6°C (101.4ºF), blood pressure is 140/90 mmHg, and finger stick glucose is 300 mg/dL. Physical exam reveals a red, swollen ear canal with white discharge. You cannot visualize the tympanic membrane. The external ear is warm and tender when palpated, and there is additional pain over the mastoid process. What is the most appropriate next step in management? A. intravenous ciprofloxacin B. oral glucocorticoids C. oral vancomycin D. surgical debridement E. topical antibiotics

A. intravenous ciprofloxacin This patient most likely has malignant external otitis based on his presentation (ear pain and mastoiditis) as well as sepsis secondary to his underlying infection and uncontrolled diabetes. This is characterized by an external ear infection with foul-smelling discharge commonly seen in diabetics and immunocompromised patients. The most common pathogen is Pseudomonas aeruginosa. Presenting symptoms are persistent pain, edema, and tenderness of the soft tissues of the ear, with a purulent discharge. Fever is uncommon but can occur, and some patients present with a facial nerve palsy. Extension of the infection to the temporal bone can result in osteomyelitis, and further extension can create cranial nerve palsies and possibly a central nervous system (CNS) infection. Patients with simple infections are treated with topical ear drop preparations. Preparations often consist of acetic acid, antibiotics, and glucocorticoids. Acetic acid changes the pH of the ear canal, and steroids help with the inflammation. The antibiotics cover the common pathogens. Ciprofloxacin is the best choice of the antibiotics listed; however, given rising resistance rates, some hospitals may favor the use of piperacillin/tazobactam or another extended-spectrum cephalosporin for initial intravenous therapy. Severe cases with extension into the adjacent bone, such as in this case, may require intravenous antibiotics based on patient presentation in addition to topical preparations once surgical debridement has been achieved.

A 55-year-old African American male presents to the outpatient clinic for his annual physical examination. The patient has a history of type II diabetes mellitus and has recently been diagnosed with hypertension. On physical examination, vital signs reveal a temperature of 99.0 degrees Fahrenheit, blood pressure of 146/98 mmHg, pulse of 78/min, and respirations of 16/min. He also has a positive urine microalbumin test. According to JNC-8 guidelines, the best initial management of this patient's blood pressure is: You answered this question incorrectly A. lisinopril B. metoprolol C. furosemide ]D. hydrochlorothiazide E. labetalol

A. lisinopril Know the indications and contraindications for anti-hypertensive medications (both drug classes, as well as, specific medicines). ACE inhibitors such as lisinopril are first-line for the treatment of hypertension in diabetic patients with CKD. ACE inhibitors are not the first line treatment for hypertension in African American patients. However, ACE inhibitors are considered first line treatments with all patients, regardless of race in the settings of CKD and hypertension, to help improve kidney outcomes. Labetalol is useful in the treatment of hypertensive emergencies Hydrochlorothiazide is the correct initial treatment for diabetic hypertensive African American patients without evidence of CKD.

A 68-year-old man with no significant past medical history presents to your office complaining of back pain. He says that the pain has been progressively worsening over the past two years. Upon further questioning you find that the pain radiates to his buttock and left leg, is worse with walking and is improved when he sits down. He used to go for long walks to get some exercise but now can only tolerate exercising on a stationary bike. Physical exam is normal with a negative straight leg test. X-rays of the lumbar spine show osteophytes, disc space narrowing and bony sclerosis. What is the most likely diagnosis? A. lumbar stenosis B. peripheral vascular disease C. neuropathy D. herniated disc E. spondylolisthesis

A. lumbar stenosis The most likely diagnosis in this patient is lumbar spinal stenosis. Lumbar stenosis is a common cause of back pain especially in the elderly population. It has many causes that include spondylosis, spondylolisthesis, facet osteophytes, herniated discs and ligamentum flavum hypertrophy. It presents with low back pain that is referred to the buttocks or legs, and is usually unilateral. History and physical exam is the key to making the correct diagnosis and neurogenic claudication must be differentiated from vascular claudication. Vascular claudication is caused by decreased blood flow to the lower extremities. It may present with pain that is not affected by postural changes, pain worse with activity and better with sitting. Pulses may be decreased in patients with vascular claudication, but should be normal in patients with neurogenic claudication. Pain is relieved by riding a stationary bike in patients with neurogenic claudication because they are seated which increases the dimensions of the spinal canal thereby relieving pressure on exiting nerve roots. Patients with vascular claudication will have increased pain while riding a stationary bike because of increased metabolic demand increasing blood flow to the lower extremities. Herniated discs may cause lumbar spinal stenosis and present in a very similar manner. However, this patient's straight leg test is normal and would most likely be positive if herniation were present.

A 75-year-old male comes to see you with a complaint of sudden onset back pain last night while lifting a ladder. He complains of pain in the mid-lumbar region at the midline. The pain is described as sharp and stabbing in nature. The pain worsens with movement but improves with rest. He has tried acetaminophen for the pain without any success. He denies any fevers, chills, nausea, vomiting, or bowel or bladder problems. Physical examination reveals a positive result in the test performed in the video exhibit (straight leg raise). The patient has no other significant medical history. What test or procedure would be most useful in determining the etiology of this patient's symptoms? A. magnetic resonance imaging of the spine B. plain x-ray films of the spine C. computed tomography scan myelography D. electromyography E. surgical evaluation

A. magnetic resonance imaging of the spine Magnetic resonance imaging is by far the most commonly ordered (gold standard) test to evaluate patients with suspected disc herniation. The straight leg raise, also called Lasègue sign, Lasègue test, or Lazarevic sign, is a test done during the physical examination to determine whether a patient with low back pain has an underlying herniated disc, often located at L5 (fifth lumbarspinal nerve). The straight leg test is performed with the patient lying down on his or her back on an examination table or exam floor; the examiner lifts the patient's leg while the knee is straight. A variation is to lift the leg while the patient is sitting; however, this reduces the sensitivity of the test. In order to make this test more specific, the ankle can be dorsiflexed and the cervical spine flexed. This increases the stretching of the nerve root and dura.The major finding on plain radiographs of patients with a herniated disc is decreased disc height. Radiographs have limited diagnostic value for herniated disc because degenerative changes are age related and are equally present in asymptomatic and symptomatic persons. Neurodiagnostic imaging modalities reveal abnormalities in at least one-third of asymptomatic patients. For this reason, computed tomography (CT) also has limited diagnostic value for herniated disc. The gold standard modality for visualizing the herniated disc is magnetic resonance imaging (MRI), which has been reported to be as accurate as CT myelography in the diagnosis of thoracic and lumbar disc herniation. T1-weighted sagittal spin-echo images can confirm disc herniation; however, the size of herniation is underestimated because the low signal of the anulus merges with the low signal of the cerebrospinal fluid. Conventional T2 and T2-weighted fast spin-echo images are used in the diagnosis of degenerative disc disease. MRI also has the ability to demonstrate damage to the intervertebral disc, including anular tears and edema in the adjacent end plates. As with CT scans, MRI can reveal bulging and degenerative discs in asymptomatic persons; therefore, any management decisions should be based on the clinical findings corroborated by diagnostic test results. MRI has traditionally been used to obtain images in the axial and sagittal planes. Recent advances have brought about oblique images, which provide better views of certain anatomic structures that were not available with conventional methods. Oblique images are oriented perpendicular to the course of the neural foramen. It has been suggested that oblique MRI be added to the conventional technique to aid in the detection of foraminal impingement.

A 23-year-old female presents with a painful lump in her neck for the past 3 weeks. She states she recently recovered from a "cold." Physical exam reveals a tender, diffuse enlarged gland in the anterior aspect of the neck. There are tender and edematous tissues within the T1-T4 paravertebral musculature. She admits to fatigue and malaise. Her thyroid-stimulating hormone level is within normal limits. The next best step in management is: A. non-steroidal anti-inflammatory medications B. fine needle aspiration C. ultrasound D. obtain thyroid hormone levels E. radioactive iodine uptake scan

A. non-steroidal anti-inflammatory medications The most likely diagnosis is subacute thyroiditis, which classically presents with a tender diffusely enlarged thyroid gland for several weeks. It commonly occurs following a viral infection. Treatment is supportive with NSAIDs for pain and inflammation. If time and NSAIDs do not improve her condition an alternative diagnosis may be sought. Incorrect answers B, C, and E: FNA, ultrasound, and iodine uptake are unnecessary since this case is not suspicious for cancer. Cancer would most likely present with a painless nodular mass. Incorrect answer D: Since TSH is a more sensitive test than directly checking thyroid hormone levels and there are no symptoms of abnormal thyroid function, there is no need to check T3 and T4.

A 33-year-old HIV-positive female presents with progressive visual disturbances. Funduscopic examination reveals yellow infiltrates around the macula with perivascular exudates and hemorrhages. Osteopathic examination is significant for decreased rate and quality of the cranial rhythmic impulse. Physical examination is otherwise unremarkable. The most appropriate treatment for this condition is A. oral ganciclovir B. oral methotrexate C. oral penicillin D. oral prednisone E. oral tetracycline7

A. oral ganciclovir The findings in this patient are consistent with cytomegalovirus (CMV) retinitis. CMV retinitis is seen in HIV patients with CD4 < 50. You should suspect this diagnosis in HIV-positive patients who present with progressive visual disturbances in the presence of yellow infiltrates with hemorrhage on funduscopic examination. Treatment of this disorder includes oral ganciclovir, foscarnet, and cidofovir. Ganciclovir is the mainstay treatment and is most likely to show up on the COMLEX.

As part of your family medicine practice you and your partners cover the local area high school sporting games as a service to the community. At the basketball game you are covering, a 16-year-old female sustains an elbow to the mouth. Several of her front teeth are knocked out of their sockets and are lying on the basketball court. After emergently calling the local dentist for an immediate appointment, what is the most appropriate additional step that should take place to protect the avulsed teeth? A. rinse the teeth with saline and place them in milk for transportation B. rinse the teeth with saline and place them on ice for transportation C. scrub the roots with saline and place the teeth back into their sockets for transportation D. scrub the teeth with saline and place them in milk for transportation E. scrub the teeth with saline and place them on ice for transportation

A. rinse the teeth with saline and place them in milk for transportation Bottom Line: With an avulsed tooth, do not touch the root and only handle the tooth by the crown. Gentle debridement with saline is acceptable, and reimplantation should be attempted. Consult a dental or oral maxillofacial surgeon for splinting and further evaluation. If the tooth was absent for less than 20 minutes, the prognosis is better. All periodontal ligament cells die if the tooth is out of the socket longer than 60 minutes. An avulsed tooth is a medical emergency and should be replaced by a dentist immediately. The likelihood of the tooth's survival depends on the length of time that the tooth is out of the socket and the degree to which the periodontal ligament is damaged. The primary goal of rapid reimplantation is to preserve the periodontal ligament, not the tooth. The avulsed tooth inevitably requires a root canal; however, if the periodontal ligament survives, the degree and timeliness of root resorption are improved and ankylosis is decreased. The following guidelines are recommended for prehospital care: Do not touch the root, handle the tooth by the crown only, and attempt reimplantation in the field. If unable to reimplant, use one of the following carrier media (in order of preference): Hanks solution: This pH-preserving fluid is best used with a trauma-reducing suspension apparatus. Milk: Shown to maintain vitality of periodontal ligament cells for 3 hours, milk is relatively bacteria-free with a pH and osmolarity compatible with vital cells. Saline: Saline is isotonic and sterile. Saliva: Saliva keeps the tooth moist; however, it is not ideal because of incompatible osmolarity, pH, and presence of bacteria. Water: This is the least desirable transport medium because it results in hypotonic rapid cell lysis. As mentioned above, the most appropriate answer choice that was available for transportation was milk. Furthermore, scrubbing the teeth prior to going to the emergency department or dental appointment is never appropriate. Saline may be used to wash off debris, and reimplantation should be attempted. An avulsed tooth is a medical emergency and should be replaced by a dentist immediately. The likelihood of the tooth's survival depends on the length of time that the tooth is out of the socket and the degree to which the periodontal ligament is damaged. The primary goal of rapid reimplantation is to preserve the periodontal ligament, not the tooth. The avulsed tooth inevitably requires a root canal; however, if the periodontal ligament survives, the degree and timeliness of root resorption are improved and ankylosis is decreased. The following guidelines are recommended for prehospital care: Do not touch the root, handle the tooth by the crown only, and attempt reimplantation in the field. If unable to reimplant, use one of the following carrier media (in order of preference): Hanks solution: This pH-preserving fluid is best used with a trauma-reducing suspension apparatus. Milk: Shown to maintain vitality of periodontal ligament cells for 3 hours, milk is relatively bacteria-free with a pH and osmolarity compatible with vital cells. Saline: Saline is isotonic and sterile. Saliva: Saliva keeps the tooth moist; however, it is not ideal because of incompatible osmolarity, pH, and presence of bacteria. Water: This is the least desirable transport medium because it results in hypotonic rapid cell lysis. As mentioned above, the most appropriate answer choice that was available for transportation was milk. Furthermore, scrubbing the teeth prior to going to the emergency department or dental appointment is never appropriate. Saline may be used to wash off debris, and reimplantation should be attempted.

A 65-year-old retired factory worker presents to your clinic complaining of right shoulder pain. He initially noticed the pain several months ago and thinks it is progressively worsening. The pain is 6/10, non-radiating, worse when reaching over his head, and better with rest. Some nights he wakes up because of the pain. Physical exam shows no visible deformities, no crepitus, full active and passive range of motion, strong pulses, and 5/5 MMS throughout the upper extremity. The patient's pain is exacerbated when you forward flex the arm 180 degrees while stabilizing the scapula. X-rays of the shoulder are normal. What is the most likely diagnosis? A. subacromial bursitis B. rotator cuff tear C. bicipital tendonitis D. labral tear E. osteoarthritis

A. subacromial bursitis

Antibody dependent cell mediated immunity

ADCC cytotoxicity is a mechanism of cell-mediated immune defense, whereby an effector cell of the immune system actively lyses a target cell, whose membrane-surface antigens have been bound by specific antibodies. It is one of the mechanisms through which antibodies, as part of the humoral immune response, can act to limit and contain infection. It is often seen in type 2 hypersensitivity reactions.

-------- is used for unstable patients. This patient does not display hemodynamic compromise. Cardioversion can also be used electively, but this patient would need a transesophageal echocardiogram first to rule out atrial thrombi and would need to be on anticoagulation before this would be considered.

Synchronized cardioversion

classic triad of nephritic syndrome, sensorineural hearing loss, and ocular abnormalities of the lens, retina, or cornea characterize this disease spectrum. Additional associations include leiomyomas and arterial aneurysms. As the disease is most often inherited in an X-linked pattern, males are more commonly affected.

Alport syndrome is an X-linked inherited disease caused by mutations in COL4A5. It is classically associated with the combination of renal, ocular, and hearing problems. "thin basement membrane nephropathy" (TBMN).

--------s a monoclonal antibody that binds to the glycoprotein receptor IIb/IIIa on activated platelets, thereby preventing platelet aggregation. It is used in the treatment of acute coronary syndrome and PCTA.

Abciximab

The use of tPA has been shown to significantly reduce, if not reverse, the course of acute ischemic stroke. Bear in mind that the use of tPA can result in intracranial hemorrhage as a major complication, and care must be taken to avoid its use in patients who are at an increased risk for intracranial hemorrhage. Knowledge of absolute and relative contraindications to tPA use is important.

According to the National Institute of Neurological Disorders in Stroke trial, administration of tissue plasminogen activator (tPA), when given within a 3 hour period from onset of acute ischemic stroke symptoms, can result in a complete or near-complete recovery of neurological function at three months. However, use of tPA has a known risk of intra-cranial hemorrhage and is thus avoided in patients with an increased risk of hemorrhage. Each patient suspicious of a stroke who may receive tPA must undergo a non-contrast computed tomography scan of the head to be sure there is no hemorrhage. If the CT head is negative, then significant stroke symptoms are assumed to be of an ischemic origin and thus amenable to TPA. A CT head in the early phase of an ischemic stroke will be normal (as in this patient) as the edematous cellular changes associated with neuronal destruction take up to 24 hours (or longer in the case of small strokes) to become apparent on CT head. An MRI will be nearly immediately positive with diffusion-weighted imaging (DWI), but could delay treatment. This patient's blood pressure is high, but absolute contraindications for blood pressure is >185 SBP and > 110 DBP. The patient did have recent surgery; however, recent surgery is a relative contraindication by the 2018 stroke guidelines if it has occurred within 14 days. Review of absolute contraindications for tPA is important prior to test day. They are as follows:- ICH on brain imaging (this includes hematomas or conversion of previous infarction)- History of any ICH or intracranial neoplasm- Severe uncontrolled HTN (parameters listed above)- Significant head trauma or intracranial or intraspinal surgery or previous completed stroke within 3 months- Known or suspected thrombocytopenia < 100,000- Known or suspected INR >1.7 or PT >15- Anticoagulation with LMWH within the past 24 hours and DOACs within the last 48 hours- Severe hypoglycemia (as these mimic stroke symptoms), once the glucose has normalized and symptoms persist, can consider TPA- Significant GI bleed within 21 days or GI malignancy- Any active internal hemorrhage- Stroke suspected to be caused by aortic dissection or by endocarditis

Achalasia treatment of choice

Achalasia presents with a "bird's beak" appearance on barium swallow. The definitive treatment is surgical myotomy with partial fundoplication. Achalasia is failure of relaxation of the lower esophageal sphincter (LES). There is progressive deterioration of the ganglion cells of the myenteric plexus in the wall of the esophagus. The esophagus becomes dilated and there is a lack of peristalsis of the esophagus. The LES is unable to coordinate with the swallowing mechanism and does not respond when swallowing takes place. On barium swallow, the patient typically has a "bird's beak" appearance due to the esophageal dilation and narrowing of the LES. Laparoscopic surgical myotomy with partial fundoplication is the definitive treatment for achalasia.

Given this patient's recent loss of her husband, her depressive symptoms, and her ability to take part in everyday life, she should most likely be diagnosed with acute grief. Grief is a difficult concept. Each person adapts and copes with grief in different ways. For many people, progress and adaptation can take up to 6 months, with many people finding that their life has not been restored to normalcy until between 6 and 12 months or longer. In times when the loss was expected, the adjustment phase may be shorter, because the patient may have undergone anticipatory grief. Some patients may have hallucinations, including visual, auditory, or tactile hallucinations, and these represent a general longing for the deceased and are generally not considered pathological.

Acute grief is a normal reaction to the loss of a loved one and can be distinguished from major depression using careful history taking. If patients meet the criteria for acute depression while in a state of acute grief, they should be treated as such.

--------of the lung is described histologically by glandular formation with mucin production identified on periodic acid-Schiff staining.

Adenocarcinoma

essential medical therapy for cholangitis?

Administration of broad-spectrum intravenous antibiotics and correction of fluid and electrolyte imbalances constitute essential medical care for cholangitis. cholangitis, one should expect dilated intrahepatic ducts

--- test is occlusion of the radial and ulnar arteries with pumping of the fist, then releasing 1 artery. A positive test is a delay or absence of blood returning to the palm suggestive of compromise in flow of the artery released.

Allen's test

--------Patients will typically have fever, rash, white blood cell casts, hematuria, eosinophilia, and/or eosinophiluria. It is typically caused by infection, drugs including NSAIDs, penicillin, cephalosporins, and phenytoin.

Allergic interstitial nephritis is also known as tubulointerstitial nephritis.

Patients who undergo chorionic villous sampling prior to 9 weeks of gestation are at an increased risk for developing fetal limb abnormalities. Although preterm labor, PROM, and limb abnormalities are all potential complications of the procedure, performing CVS prior to 9 weeks of gestation specifically places the fetus at an increased risk for limb abnormalities. This is thought to be due to vascular interruption that occurs during the procedure. CVS does not increase the risk of fetal cardiac defects. Chorionic villous sampling (CVS) can be used sooner than amniocentesis to assess fetal karyotype and is typically performed between 9 and 11 weeks of gestation. CVS involves transcervical or transabdominal aspiration of placental chorionic villi tissue. The advantage of using it is that it has a diagnostic accuracy comparable to that of amniocentesis, whereas the disadvantage is that is carries a risk of fetal loss and it cannot detect open neural tube defects. Amniocentesis is performed at 15 to 20 weeks and consists of transabdominal aspiration of amniotic fluid using ultrasound-guided needle evaluation of fetal cells for genetic studies.

Although preterm labor, premature rupture of membranes (PROM), and limb abnormalities are all potential complications of the procedure, performing CVS prior to 9 weeks of gestation specifically places the fetus at an increased risk for limb abnormalities.

------is used to treat toxicity from tissue plasminogen activator (tPA) and streptokinase. tPA toxicity is followed by measuring aPTT and PT levels.

Aminocaproic acid

Teratology is an important subject on COMLEX exams. Be able to define the effects of the following teratogens: ACEi's, alcohol, aminoglycosides, cocaine, DES, folate antagonists, lithium, tetracyclines, thalidomide, valproate, warfarin, and phenytoin A 23-year-old female at 13 weeks gestation presents to your clinic complaining of burning on urination. She has taken multiple medications that have not resolved her problem. Cultures grow gram-negative rods. She is treated with an antibiotic that requires oxygen to be taken up into the bacterial cells. What adverse effect is most likely to occur in the fetus due to this antibiotic choice? A-Bone damage B-Cartilage damage C-Gray baby syndrome D-Kernicterus E-CN VIII damage.

Aminoglycosides should not be used in pregnant patients due to an increased risk of renal damage and CN VIII damage.

amiodarone is used to treat atrial and ventricular dysrhythmias. It acts n the third phase of the cardiac cycle. And one of the side effects in the lungs will be?

Amiodarone induced pulmonary toxicity which will be seen on plain film of the chest as interstitial and alveolar infiltrates. presence of high-attenuationg infiltrates may be seen on CT scan of the chest because of iodine deposition. best treatment is corticosteroids. Amiodarone pulmonary toxicity can present as community acquired pneumonia that is unresponsive to antibiotic therapy. Interstitial fibrosis will be found on chest radiographs.

------- is the recommended test of choice for genetic diagnosis in the case of an abnormal quad screen.

Amniocentesis is the recommended test of choice for genetic diagnosis in the case of an abnormal quad screen. This procedure is the least invasive and the safest of the procedures offered to collect fetal genetic material.

Bottom Line: Leg length discrepancy is assessed by measuring the distance from the anterior superior iliac spine (ASIS) to the medial malleolus and comparing to the contralateral side.COMBANK Insight : Knowing basic physical exam components will get you some easy points on test day.Anatomical leg length discrepancies most commonly occur following unilateral total hip replacements. Structural findings include the following: sacral base unleveling (the sacral base will be lower on the side of the short leg), anterior innominate on the side of the short leg, posterior innominate on the side of the long leg, and a lumbar dysfunction (type I) with sidebending away from and rotation toward the short leg. Leg length discrepancy measurements are taken from the anterior superior iliac spine (ASIS) to the medial malleolus of the same extremity. Comparison is made from one side to the other. These are the generally accepted landmarks as they are stable and easily identified on most patients.

Anatomical leg length discrepancies most commonly occur following unilateral total hip replacements. Structural findings include the following: sacral base unleveling (the sacral base will be lower on the side of the short leg), anterior innominate on the side of the short leg, posterior innominate on the side of the long leg, and a lumbar dysfunction (type I) with sidebending away from and rotation toward the short leg. Leg length discrepancy measurements are taken from the anterior superior iliac spine (ASIS) to the medial malleolus of the same extremity. Comparison is made from one side to the other. These are the generally accepted landmarks as they are stable and easily identified on most patients.

------ is often associated with one or more of several articular and periarticular extraspinal features. It is important to recognize the common symptoms, such as low back pain that is better with exercise and worse at night, and stiffness. It is also important to know the common associated conditions.

Ankylosing spondylitis It is often associated with articular, non-articular, and periarticular extraspinal features. These features include synovitis, enthesitis, dactylitis, uveitis, psoriasis, and inflammatory bowel disease (IBD). Enthesitis is an inflammation of the region of attachment of tendons and ligaments to bone. Enthesitis manifests as pain, stiffness, and tenderness of insertions, usually without much swelling, Although an exception is that enthesitis at the achilles tendon may present with swelling. Other areas of enthesitis associated with AS include the calcaneal attachment of the plantar fascia, the shoulders, the costochondral junctions, the manubriosternal and sternoclavicular joints, and the superior iliac crest.

Listeria monocytogenes is a common cause of meningitis in infants and elderly patients. It can be found in soft cheeses and processed meats such as hotdogs. It may appear in a question that states the organism has tumbling motility. It is not a common organism associated with cystic fibrosis.

true

Bioterrorism-related anthrax exposure, such as through white powder in the mail, carries with it a risk of inhalational anthrax exposure. Prophylactic treatment is with a 60-day course of ciprofloxacin or doxycycline.

Anthrax, caused by Bacillus anthracis, is an uncommon illness in the United States. From 1980 through 2000, only seven cases of anthrax were reported to CDC. In 2001, 22 confirmed or suspected cases of bioterrorism-related anthrax occurred in the United States, when B. anthracis spores in powder-containing envelopes were sent through the mail. There are three manifestations of anthrax, which are cutaneous, inhalational, and alimentary tract. Cutaneous anthrax is the most common form of the disease. Naturally occurring cases of cutaneous anthrax develop after spores of B. anthracis are introduced subcutaneously, often as a result of contact with infected animals or animal products. Cuts or abrasions increase susceptibility to cutaneous infection. Inhalation anthrax results from the inhalation of B. anthracis spore-containing particles. This may occur when anthrax spores are aerosolized while working with contaminated animal products such as wool, hair, or hides. It has also resulted from inhalation of weaponized and intentionally released spore preparations. Alimentary tract anthrax presents as one of two clinical forms, which are oropharyngeal or gastrointestinal anthrax. B. anthracis has been reported to infect all regions of the alimentary tract from the mouth to the ascending colon. The disease develops following the consumption of undercooked infected meat from animals infected with anthrax. The patient presentation is consistent with a bioterrorism-associated anthrax exposure. All patients with bioterrorism-related cutaneous anthrax are at risk for inhalation anthrax due to potential aerosol exposure; thus, the duration of antimicrobial therapy should be 60 days to provide a full course of postexposure prophylaxis against inhalation anthrax.

---- is seen with administration of chloramphenical and is not a side effect of gentamicin.

Aplastic anemia

The ----- allele has been associated with the development of Alzheimer's dementia.

ApoE

e.coli uti treatment

Appropriate antibiotic regimens include nitrofurantoin 100 mg twice a day for 5 days or trimethoprim-sulfamethoxazole double strength twice a day for 3 days. Ciprofloxacin 500 mg twice a day for 3 days is an acceptable alternative for patients with allergies. However, ciprofloxacin should not be used in pregnant women Without proper treatment of cystitis, the infection can ascend into the kidneys (pyelonephritis). Mild to moderate pyelonephritis in a young, healthy patient can be treated as an outpatient. Ciprofloxacin 500 mg twice a day for 7 days is the treatment of choice for uncomplicated pyelonephritis. In women with severe pyelonephritis, inpatient therapy with intravenous antibiotic therapy is recommended. The antibiotics recommended vary based on patient tolerance, bacterial susceptibility, and local resistance data. The most common regimens include a fluoroquinolone, an aminoglycoside, an extended-spectrum cephalosporin, an extended-spectrum penicillin, or a carbapenem. All pregnant women with pyelonephritis require inpatient treatment with intravenous antibiotics.

In the ED, the patient develops fever, tachycardia, worsening abdominal pain. X-rays reveal air around the intestine and under the diaphragm. What is the most important step in the management of this patient? A. Insertion of nasogastric tube B. Emergent surgical intervention C. Endoscopic retrograde cholangiopancreatography D. Diagnostic ultrasonography E. Start the patient on a clear liquid diet

B. Emergent surgical intervention

A 66-year-old male electrician presents to the outpatient clinic with neck pain that he has had for 10 years. He describes a focal, achy pain toward the top of his neck that is worse with flexion. He denies any weakness or radiating pain. His neurologic exam is unremarkable. On osteopathic structural exam, his occipito-atlantal (OA) joint is restricted in translation to the left and becomes more restricted in a flexed position. The correct diagnosis of this somatic dysfunction is: A. extended, sidebent left, rotated left B. extended, sidebent left, rotated right C. extended, sidebent right, rotated right D. flexed, sidebent left, rotated right E. flexed, sidebent right, rotated left

B) The OA joint sidebends and rotates in opposite directions (pseudo type-I mechanics). Translation to one side induces sidebending to the opposite side. In this case, the OA is restricted from translation to the left, indicating that the OA is resisting sidebending to the right; therefore, the position of ease is sidebending left. With sidebending to the left, the OA rotates to the right. Finally, the restriction becomes worse in flexion, which indicates a position of ease in extension.

A 65 year old woman presents to the hospital with extreme fatigue and weakness. She states that she has been fatigued over the past 6 months and it has been worsening. She works as a teacher and has been having trouble making it through the day. She also mentions that she notices that if she lightly bumps into a desk she will get a bruise. On exam she has numerous bruises on various parts of her body at various stages of healing. Her face is pale. Her neuro exam is normal but she is generally weak. Her vitals are stable at rest, but she seems to become short of breath upon walking the long hallway to the bathroom. Auer rods are seen on blood smear. A) Acute lymphocytic leukmia B) Acute myelocytic leukemia C) Chronic lymphocytic leukemia D) Chronic myelocytic leukemia E) Hodgkin's lymphoma

B) Acute myelocytic leukemia AML is the most common acute leukemia in adults. It accounts for less than 10% of leukemias in children under 10 years old. The median age of diagnosis is 65 years old. It results from a proliferation of myeloid cells. AML has been associated with both genetic abnormalities and environmental factors. Typical symptoms include: fatigue, history of recurrent infections, fever, pallor, easy bruising, and hepatosplenomegaly. Hepatosplenomegally is only seen in < 10% of patients. Symptoms of anemia (shortness of breath, weakness, dyspnea on exertion) are generally present. Lymphadenopathy is uncommon. General fatigue is usually the presenting symptom and will likely be present for a while before diagnosis. If fever is present it is most likely related to an infection and should be rapidly worked up. Pancytopenia is common on laboratory evaluation. Blood smear shows large myeloblasts with notched nuclei and Auer rods. Once the diagnosis of acute myeloid leukemia (AML) is established, induction chemotherapy is given with the goal of rapidly restoring normal bone marrow function.

-------helps to prevent people from suddenly losing health coverage when transitioning between jobs, or when work hours are cut.

COBRA (Consolidated Omnibus Budget Reconciliation Act)

The most potential life-threatening complication in patients taking this aminoglycosides-gentamicin A. Acute cholestatic hepatitis B. Acute tubular necrosis C. Aplastic anemia D. Cardiac arrhythmias E. Fanconi syndrome

B. Acute tubular necrosis Gentamicin, like other aminoglycosides, can cause nephrotoxicity through the inhibition of protein synthesis in renal cells. The patient may subsequently develop necrosis of cells in the proximal tubule, resulting in acute tubular necrosis, which can lead to acute renal failure. This is the most severe potential adverse effect of aminoglycoside therapy. BUN and creatinine levels should be monitored in patients receiving treatment with aminoglycoside antibiotics, given their nephrotoxic potential. Fanconi syndrome is a side effect of tetracyclines but may also be caused by other medications such as gentamycin. However, acute tubular necrosis would be more likely in this case

A 19-year-old girl left home for college two-months ago. This is the first time she has lived away from her parents. She has no significant past medical history. She is constantly worried about her grades. She has nightmares about failing her exams. She has trouble concentrating, sleeping and has lost her appetite. When she received 80% on her first physics test she locked herself in her room for two days. The most likely diagnosis is: A. Acute stress disorder B. Adjustment disorder C. Borderline personality disorder D. Depression E. Generalized anxiety disorder

B. Adjustment disorder Adjustment disorder develops within ----- of an identifiable stressor. The symptoms are in excess of what would be expected from the stressor. This patient has started college and was separated from her family for the first time (stressors) and as a result is experiencing symptoms of depression and anxiety that are significantly impairing her function.

A 49-year-old postal worker presents to the office with neck and arm pain. She was reaching toward a distant mailbox when she felt a "pop" in her neck and immediately experienced shooting pains down the side of her right upper arm. She continues to have numbness into the outside part of her right arm that worsens with neck extension and right sidebending. Physical exam reveals right biceps tendon reflex of 1/4 with the left at 2/4, 4/5 strength with right shoulder abduction and elbow flexion, and decreased sensation to pinprick over the deltoid area. Given this patient's symptoms, which nerve root was most likely injured? A. C4 B. C5 C. C6 D. C7 E. C8

B. C5 This patient presents with symptoms consistent with C5 nerve root impingement. The C5 dermatome is located along the proximal lateral arm to the proximal forearm. Muscles with C5 innervation will exhibit weakness; this includes the deltoid, supraspinatus, infraspinatus, pectoralis major and minor, coracobrachialis, and biceps muscles. The biceps tendon deep tendon reflex (DTR) is often reduced in a C5 nerve root impingement. Treatment options are often predicated on the severity of the nerve root impingement. Mild impingements are often treated conservatively with rest and physical therapy to the neck and arms, while severe impingements with significant denervation or associated cervical instability require surgical considerations.

The team physician places the knee in 30 degrees of flexion and stabilizes the femur with her nondominant hand. She then applies an anterior force to the distal leg to assess forward translation. What is the name of this test? A. anterior drawer test B. Lachman test C. pivot shift test D. posterior drawer test E. Spurling test

B. Lachman test The Lachman test is the test that you should perform when examining a patient with suspected anterior cruciate ligament (ACL) injury. It is the most sensitive test in assessing for an acute ACL rupture. To perform this test, you place the patient's knee in 20 to 30 degrees of flexion. Stabilize the patient's femur with your nondominant hand. Apply an anterior force to the proximal calf. Check for the amount of displacement in millimeters and what the quality of the end point is. A positive test is one in which there is asymmetry in side-to-side laxity or there is a soft (rather than firm or marginal) end point. A side-to-side difference of 3 mm is another indication that this is a positive test. Other physical exam tests for ACL injury include the pivot shift test or anterior drawer test.

A 73-year-old male presents to his primary care physician complaining of a skin rash. Physical examination reveals several round-to-oval erythematous scaly patches and plaques on the lower extremities. The patient states that the lesions worsen during the winter months. Skin scraping and potassium hydroxide (KOH) preparation of the lesions is negative. The most likely diagnosis is: A. Bullous pemphigoid B. Nummular eczema C. Seborrheic keratosis D. Tinea corporis E. Tinea versicolor

B. Nummular eczema Nummular eczema presents with round, coinlike, dry, scaly, and erythematous plaques, typically bilateral and on the lower extremities. Management is with topical corticosteroids.

A 72-year-old female lives in a rural town with only one family practice physician, who practices alone. The next closest physician's office is 20 miles away. She has not seen a physician in over ten years and is concerned about her general health. Upon calling the doctor's office, she is told that he is not taking new patients at this time and is unwilling to see her. The patient becomes infuriated and threatens to sue the doctor. Which of the following statement is true concerning this situation? A. The patient is likely to win the suit B. The physician is not legally obligated to see the patient and is not responsible for her referral C. The physician is not obligated to see her but must refer her to a physician that is willing to treat her D. The physician is obligated to see her because she is elderly E. The physician must offer the patient at least one yearly exam

B. The physician is not legally obligated to see the patient and is not responsible for her referral Physicians are under no legal obligation to accept new patients to their practice. A physician in private practice is not under the same legal jurisdiction that is present in a hospital setting. This holds true for both primary care doctors, as well as specialists.

chronic mesenteric ischemia diagnosis

Bottom Line: For chronic mesenteric ischemia, the diagnostic test of choice is an angiogram. Physical exam is usually unrevealing. Angiogram is considered to be a test of choice when ruling out chronic mesenteric ischemia. After the diagnosis is made by an angiogram, patients should undergo surgery because of the risk of continued weight loss, acute infarction, perforation, sepsis, and death. Treatment options include surgical intervention, stent placements, or medical management with anticoagulants and vasodilators. Unlike acute mesenteric ischemia, testing can be performed as an outpatient, so long as the patient is closely followed, as chronic mesenteric ischemia is not an acute emergency.

You are a resident on the internal medicine floor and you are asked to see a 25-year-old man complaining of headache, dizziness, visual difficulties, and balance problems. You look at the studies performed and find the following: hematocrit of 55% (reference range: 42-52%), increased protein and RBC's in the urine. Physical examination shows an enlarged liver and spleen along with the findings seen on the video exhibit. Ultrasound of the pancreas reveals cysts. Direct ophthalmoscopic examination reveals two dilated arteries leading from the disc to a peripheral tumor with an engorged vein. What is the most likely diagnosis? A. Autosomal-dominant polycystic kidney disease B. Von Hippel-Lindau C. Multiple paragangliomas syndrome D. Tuberous sclerosis complex E. Neurosyphilis

B. Von Hippel-Lindau note: If a patient is ataxic and Romberg's test is not positive, it suggests that ataxia is cerebellar in nature. If a patient is ataxic and Romberg's test is not positive, it suggests that ataxia is cerebellar in nature. A patient requires at least two of the three following senses to maintain balance while standing: proprioception (the ability to know one's body in space); vestibular function (the ability to know one's head position in space); and vision (which can be used to monitor [and adjust for] changes in body position). In the Romberg test, the standing patient is asked to close his or her eyes. A loss of balance is interpreted as a positive Romberg's test.

A 47-year-old male presents to his primary care physician after experiencing persistent symptoms of erectile dysfunction despite medication. He has a past medical history of diabetes, tobacco abuse, and hypertension. Upon further questioning, he reports gluteal cramping with activity that abates with rest. Physical examination reveals decreased femoral pulses and lower extremity muscle atrophy, pallor, and hair loss bilaterally. The most likely diagnosis is: A. acute peripheral ischemia B. aortoiliac occlusive disease C. deep vein thrombosis D. lymphedema E. neurogenic claudication

B. aortoiliac occlusive disease The most likely diagnosis is aortoiliac occlusive disease, also known as Leriche syndrome. Leriche syndrome is a subtype of peripheral artery disease (PAD) that involves pathology of the aortoiliac arterial system. PAD occurs as the blood supply to the extremities becomes occluded as a result of atherosclerotic plaque accumulation. The lower extremities are more commonly affected than the upper extremities. The clinical signs and symptoms depend on which vessels are involved, the extent and rate of obstruction, and the presence or absence of collateral blood flow.Patients often present with intermittent vascular claudication, which is defined as reproducible leg pain that occurs with activity and is relieved with rest. As the disease progresses, pain occurs at rest and affects the distal extremities. Dorsal foot ulcerations may occur secondary to poor perfusion. Aortoiliac disease may present with typical signs and symptoms of PAD in addition to buttock claudication, decreased femoral pulses, and male impotence. The measurement of ankle and brachial (ABI) systolic blood pressures can provide objective evidence of atherosclerosis and support the diagnosis of PAD. Doppler ultrasound may be used to help identify stenosis and occlusion. Treatment of PAD and its subtypes involves controlling any underlying conditions such as diabetes, tobacco use, and hypertension. ASA, cilostazol, and thromboxane inhibitors may improve symptoms. Anticoagulants such as heparin, low molecular weight heparins, and warfarin may be used to prevent clot formation. Surgery or amputation may be used when medical treatment fails.

A 53-year-old female is brought to the emergency department by her daughter, who just arrived home from work and noted that her mother appeared very confused. The patient complains of a headache, nausea, and feelings of dizziness. The daughter reports that her mother was fine just 1 day ago and has had no recent illnesses or trauma. She reports that her mother has been grieving over the loss of her youngest son for the past 6 months and that she even tried to commit suicide about 2 months ago by overdosing on aspirin. On physical exam, the patient is found to be afebrile, tachycardic, and stuporous. She is unable to ambulate without assistance; however, she does not appear to have any focal neurologic deficits. Pulse oximetry is 98%, and arterial blood gas analysis reveals a normal PO2, with a metabolic acidosis. Based on this information, what is the most likely diagnosis? A. aspirin overdose B. carbon monoxide poisoning C. influenza virus D. sepsis E. stroke

B. carbon monoxide poisoning Suspect carbon monoxide poisoning in all patients who present with lethargy and acute mental status changes, especially if they have a history of depression or prior suicide attempts. The early signs of carbon monoxide poisoning are vague and can sometimes resemble flu-like symptoms. The patient may present with headache, confusion, dizziness, nausea, memory problems, and convulsions. Always consider carbon monoxide poisoning in the differential of any patient with prior suicide attempts who presents with headaches, lethargy, or confusion, because these are the common signs.CO combines preferentially with hemoglobin to produce HbCO, displacing oxygen and reducing systemic arterial oxygen content. CO binds reversibly to hemoglobin with an affinity 200 to 230 times that of oxygen. Consequently, relatively minute concentrations of the gas in the environment can result in toxic concentrations in human blood.Physical exam will show tachycardia and either hypo- or hypertension along with altered mentation. The classic cherry-red skin is rare but is commonly mentioned in testing. Arterial blood gas (ABG) analysis will show a normal arterial oxygen level because oxygen diffusion is not affected. The only abnormality on an ABG may be metabolic acidosis, which is a consequence of inadequate oxygen delivery to the peripheral tissues, resulting an anaerobic metabolism and lactic acid production. A standard bedside pulse oximeter is unable to differentiate between HbO2 and HbCO, which is why the pulse oximeter will usually show a normal oxygen saturation. Carboxyhemoglobin must be measured to make the diagnosis.Treatment for CO poisoning is oxygen. But, because hemoglobin has a higher affinity for CO than oxygen, oxygen must be given in large quantities. Comatose patients should be intubated and vented with 100% oxygen. Patients who can be managed in the ER can be treated with high flow oxygen. If available, hyperbaric oxygen can be used to drive up the partial pressure of O2 beyond standard atmospheric levels.Note the following:--CO poisoning usually occurs in the winter season when people use alternate sources for heating with improper ventilation; everyone in the house should have symptoms in this case.--CO poisoning can also occur in older vehicles with a leak in the tailpipe allowing exhaust fumes to enter the cabin of the vehicle.--CO poisoning can occur when people are off roading on ATVs and they get stuck in the mud, breathing in the fumes as they try to rev the engine to get unstuck.--CO poisoning is common in house fires, but do not forget about cyanide poisoning in this scenario either.

If the patient were to return to play before symptoms had resolved and suffered a second concussion, what is the most serious complication that may arise? A. amnesia B. cerebral edema C. epidural hematoma[ D. learning disabilities E. spinal cord injury

B. cerebral edema Cerebral edema and death are possible and well documented if an athlete suffers a second impact before recovering from the initial concussion, a phenomenon known as second-impact syndrome. Some debate exists over whether a single impact may, in some cases, be enough to cause edema. A second hit places the patient at much higher risk, especially among teenage athletes.

A 48-year-old postal worker presents to the emergency department with flu-like symptoms for several days, along with high-grade fever to 40.6°C (105°F), chest pain, diaphoresis, and dyspnea. Chest x-rays reveal the presence of a severe pneumonia. Gram staining and polymerase chain reaction confirm Bacillus anthracis. Which of the following is the best treatment regimen for inhalation anthrax? A. anthrax immunoglobulin B. ciprofloxacin plus clindamycin plus anthrax immunoglobulin C. oral ciprofloxacin for 7-10 days D. oral doxycycline for 7-10 days E. oral streptomycin for 7-10 days

B. ciprofloxacin plus clindamycin plus anthrax immunoglobulin Inhalational anthrax usually occurs in textile and tanning industries among workers handling contaminated animal wool, hair, and hides. Inhalational anthrax begins abruptly, usually 1 to 3 days (range, 1 to 60 days) after inhaling anthrax spores, which are 1 to 5 µm in diameter. The number of spores needed to cause inhalational anthrax varies. As evidenced by anthrax cases in the United States in 2001, fewer spores of weapon-grade anthrax may be required to cause inhalational anthrax. Patients with inhalational anthrax present initially with nonspecific symptoms, including a low-grade fever and an unproductive cough. They may report substernal discomfort early in the illness. After initial improvement, inhalational anthrax progresses rapidly, causing hemorrhagic mediastinitis and rapid clinical deterioration. The following symptoms may be present: high fever, severe shortness of breath, tachypnea, cyanosis, profuse diaphoresis, hematemesis, and chest pain, which may be severe enough to mimic acute myocardial infarction. Treatment of inhalational anthrax without meningitis includes ciprofloxacin plus clindamycin plus anthrax immunoglobulin or raxibacumab.

Given the most likely diagnosis of celiac disease, the patient is most at risk for developing A. esophageal carcinoma B. compression fracture C. gallstones D. sclerosing cholangitis E. uveitis

B. compression fracture Celiac's disease is associated with decreased Vit D absorption, which leads to decreased bone mineral density. Individuals are at a slight increased risk for fragility type fractures.

A 66-year-old male presents to your office complaining of pain in the lower extremities that is associated with walking and relieved by rest. Physical examination of the legs demonstrates atrophic skin changes with diminished pedal pulses. The patient is morbidly obese and has a positive smoking history. What is the most appropriate initial treatment? A. clopidogrel B. conservative therapy (nonpharmacologic) C. metoprolol D. pedal pumping E. revascularization of the extremities

B. conservative therapy (nonpharmacologic) Pain in the lower extremities that is aggravated by exercise and relieved with rest is highly indicative of claudication, due to atherosclerotic disease. The patient's presentation offers many options for conservative treatment, including smoking cessation and weight loss. On the COMLEX, it is important to always think like a primary care physician, and start with conservative management first. Atrophic changes such as hair loss, thickening of nails, and shiny skin are also supportive of this diagnosis. The best treatment for this condition is conservative therapy with smoking cessation, exercise, and control of diabetes mellitus, hypertension, and dyslipidemia. Beta-blockers such as metoprolol may worsen the claudication due to beta-2 receptor blockade, and should only be used in select circumstances. Pedal pumping is not recommended in patients with atherosclerotic disease, as it may promote clot embolization in the lower extremities. Revascularization of the extremities should be reserved for patients who develop foot pain at rest, or those who cannot fulfill current lifestyle or work obligations. Most patients with a diagnosis of claudication due to PAD should be treated initially with a medical therapy regimen that includes risk factor modification and exercise therapy, and possibly pharmacologic therapy, rather than vascular intervention or surgery. A selected subset of patients may be appropriate for initial intervention.

An 8-year-old male presents to the hospital emergency department with symptoms of abdominal pain for the past 2 days. His mother reports that his appetite has been diminished and he has been soiling his underwear for the past 3 to 4 months. A plain radiograph is ordered of the abdomen, which a reveals a large amount of stool throughout his colon. Upon physical examination, bowel sounds are present, and the abdomen is soft and nontender. There are marked tissue texture changes in the L1-L4 paraspinal musculature. What is the most likely cause of these symptoms? A. Campylobacter jejuni infection B. constipation C. gastritis D. Hirschsprung disease E. viral gastroenteritis

B. constipation Constipation is a common presentation in pediatric patients. On average, patients will have lived with constipation and many of its complications for 5 years. The child in this stem has likely been having difficulty with constipation for a prolonged period and has now reached a behavioral threshold where his not taking time to have a bowel movement has resulted in liquid stool "escaping" from around the large mass of hard stool in his colon. This is called encopresis.

A 45-year-old male presents to the Emergency Department experiencing right buttock and right calf pain. History reveals that he had this pain for three months. The pain is intermittent, sharp in nature, and worsens at night or when he sneezes. He has been placed on a weight loss program as recommended by his physician. He currently weighs 140 kg (310 lb). An expected physical finding is A. absent plantar flexion during calf compression B. decreased deep tendon reflexes C. decreased distal pulses D. increased deep tendon reflexes E. thick hardened veins on palpation

B. decreased deep tendon reflexes This patient is presenting with symptoms of sciatica, or compression of the sciatic nerve. Sciatica is a very common pathology that affects males more than females. Incidence peaks in the 4th or 5th decade of life. Other risk factors include obesity, cigarette smoking, diabetes and sedentary lifestyle. Most patients present with low back pain (not required) that radiates unilaterally down one leg for a few months exacerbated by increased intra-abdominal pressure or valsalva (sneezing, coughing, or laughing), sitting or standing, nighttime. Patients may get relief when bending backwards. Examination may reveal non-midline tenderness in the lumbar region, positive straight leg raise test, decreased or absent reflexes, weakness, or numbness and tingling. Work up should include plain radiographs, magnetic resonance imaging to evaluate for spinal cord compression. Treatment includes reduced activity for a few days (strict bed rest is no longer recommended), avoiding heavy lifting, physical therapy to strengthen abdominal muscles, and non-steroidal anti-inflammatory medications. If pain persists, other interventions may be considered such as steroidal epidural injections or surgery.

A 62-year-old male presents to your office with concern for yellow discoloration of his eyes and skin. He has a 70-pack-year smoking history, eats a diet high in fat, and has a history of uncontrolled hypertension. Physical exam reveals a cachectic-looking male and a nontender, palpable mass in the right upper quadrant of the abdomen. The patient has scleral icterus. Laboratory demonstrates an elevated bilirubin with a high direct fractionation. Based on the most likely underlying diagnosis, which of the following lends toward a better prognosis? A. extensive portal venous involvement B. gastroduodenal artery involvement C. occult peritoneal metastasis D. palpable nodule at the umbilicus E. superior mesenteric artery involvement

B. gastroduodenal artery involvement The question requires knowledge of pancreatic cancer and applied anatomy. Tumors of the pancreatic head require a Whipple procedure for oncologic resection. The blood supply to the foregut is tremendously redundant, allowing gastroduodenal arterial resection without significant sequelae. The gastroduodenal artery (GDA) is resected during any Whipple procedure with flow to the duodenum via the inferior pancreaticoduodenal artery. The stomach has flow via the left and right gastric arteries as well as the short gastric arteries. The GDA can be ligated or embolized in upper gastrointestinal bleeding as well. The knowledge that the GDA is always resected makes this the best answer. The remaining choices make the patient unresectable and preclude a cure. Regarding pancreatic cancer in general, risk factors include chronic pancreatitis, smoking, a high-fat diet, advanced age, male gender, and a first-degree relative with the disease. It classically presents with painless, progressive obstructive jaundice. Commonly tested physical exam findings seen in pancreatic cancer patients include the Courvoisier sign (a nontender, palpable gallbladder) and Trousseau sign (migratory thrombophlebitis).The best initial diagnostic test is a CT scan of the abdomen, which may reveal a pancreatic mass, dilated pancreatic and bile ducts, hepatic metastases, or vascular involvement. If a mass is not appreciated with CT scanning, an endoscopic retrograde cholangiopancreatography (ERCP) may be used to confirm the diagnosis. If ERCP is still negative, then generally endoscopic ultrasound (EUS) is attempted.More than 50% of pancreatic cancers are adenocarcinomas that involve the head of the pancreas. Unfortunately, most patients with pancreatic cancer present with metastatic disease, and therefore, treatment is often palliative. For the approximately 10% to 20% of pancreatic head tumors that have no evidence of metastasis or major vessel involvement, pancreaticoduodenectomy (also known as the Whipple procedure) is an option. Patients with resectable tumors have a better prognosis than those with unresectable tumors, and resectable tumors typically include those of the pancreatic head, tumors with little ingrowth into the peripancreatic fat or duodenum, and tumors that have not metastasized. Tumors with a poor prognosis include those that involve vasculature such as the superior mesenteric artery, portal vein, aorta, or inferior vena cava because they are generally not resectable due to the inability to reconstruct those vascular structures. Surgical resection of cancers located in the body or tail of the pancreas consists of a distal subtotal pancreatectomy, usually combined with splenectomy, but unfortunately, these tumors generally present at a more advanced stage due to failure to compress the common bile duct and cause jaundice. Chemotherapy with fluorouracil and gemcitabine may improve short-term survival, but the long-term prognosis is poor.

A 35-year-old otherwise healthy female with no medical history presents with complaints of restlessness and trouble sleeping for the past 2 weeks, as well as a lingering sore throat. She denies drug, alcohol, or tobacco use and does not drink excessive caffeine. Her vitals are temperature of 37.8 °C (100.1 °F), blood pressure is 155/95 mmHg, heart rate of 108/min, and respiratory rate of 22/min. On physical exam there is no pharyngeal erythema, tonsillar exudates, or cervical lymphadenopathy; however, there is a mild tremor of the hands bilaterally as well as proximal muscle weakness. She reports that 3 weeks ago, she had a runny nose, fever, cough, and sore throat. The remainder of her symptoms except the sore throat have improved, and she is wondering if she might have some kind of bacterial infection. She asks for antibiotics. What is the most likely cause of this patient's symptoms? A. hyperparathyroidism B. hyperthyroidism C. polymyalgia rheumatica D. sarcoidosis E. streptococcal pharyngitis F. substance abuse

B. hyperthyroidism Hyperthyroidism can be precipitated by viral infection, and should be considered if there are typical symptoms following a viral illness with neck tenderness or signs of goiter; typical symptoms include anxiety, tachycardia, heat intolerance, muscle weakness, and hypertension. This entity may also be called de Quervain thyroiditis, subacute nonsuppurative thyroiditis, or giant cell thyroiditis. The patient is exhibiting the signs and symptoms of acute thyroiditis with resulting acute hyperthyroidism. This is a rare phenomena, most often associated with viral upper respiratory tract infection, which is thought to result in destruction of the thyroid gland. This destruction leads to the unregulated secretion of T4. The amount of hormone secreted is proportional to the amount stored, so the course of disease can be variable. Because a rise in T4 suppresses the thyroid-pituitary axis, TSH will be suppressed. After the patient has recovered, generally in 2 to 6 weeks, the thyroid will initially be unable to produce enough hormone to meet demand, and the patient will be hypothyroid for a period of time. This is generally asymptomatic and does not require replacement.Symptoms of hyperthyroidism include anxiety, heat intolerance, palpitations, tremor, tachycardia, hypertension, and proximal muscle weakness. In thyroiditis, there is generally significant neck tenderness. Sometimes, due to inflammation and edema within the thyroid gland, there is a palpable goiter. Thyroiditis is a clinical diagnosis, which can be made if the patient has the usual symptoms of hyperthyroidism, neck pain, and signs of hyperthyroidism on blood work. The usual testing strategy includes obtaining TSH, T4, and T3, as well as CRP/ESR to evaluate for a proinflammatory state. If the patient is not significantly hyperthyroid and the neck pain resolves within a few weeks, thyroid hormone levels can be retested. If they have returned to normal, then the diagnosis is confirmed. In patients with severe hyperthyroidism or severe symptoms, a radioiodine uptake scan can be performed. There should be low uptake due to low TSH and cellular destruction. If uptake is increased, then an alternative diagnosis should be entertained, such as multinodular goiter or Graves' disease.

A 27-year-old, G3P2, female at 37 weeks gestation presents to the Emergency Department after experiencing symptoms of sudden-onset abdominal pain. Her abdomen is exquisitely tender to palpation and she is contracting every two minutes on the monitor. Paraspinal tissues from T10-L2 are edematous and sharply painful with movement. Fetal heart tones show baseline 165 bpm with minimal variability. Sterile speculum examination reveals bright red bleeding from the cervical os. The pregnancy has been complicated by poorly-controlled chronic hypertension and tobacco abuse. This patient is most likely experiencing: A. Intrauterine fetal demise (IUFD) B. placental abruption C. Spontaneous labor D. placenta previa E. Braxton-Hicks Contractions

B. placental abruption' This is a classic presentation of placental abruption, which by definition refers to separation of a normally located placenta after the 20th week of gestation and prior to birth. Patients usually present with sudden-onset, painful uterine contractions with vaginal bleeding, which occur in approximately 80% of patients suffering from abruption. Typically, the uterus remains firm and tender, which is consistent with the patient in the above case. Risk factors for placental abruption include hypertension, abdominal/pelvic trauma, tobacco use, cocaine use, previous abruption, rapid decompression of a overdistended uterus, and excessive stimulation. Symptoms include painful dark vaginal bleeding that does not stop spontaneously, abdominal pain, uterine hypertonicity, and fetal distress. Its diagnosis is primarily clinical but transabdominal/transvaginal ultrasound may be used to help aid in the diagnosis. Treatment depends on severity with medical management being utilized for mild cases and delivery for severe cases. Complication includes hemorrhage and death.---Bottom Line: Suspect placental abruption in all patients complaining of painful vaginal bleeding with uterine contractions.

A diabetic mother delivers a male newborn without previous prenatal care. She reports methadone use throughout the pregnancy. During the first two hours of life the newborn is found to be irritable with a mild tremor. Capillary glucose is found to be 80 mg/dL. Venous hematocrit (Hct) found to be 69%. The most likely diagnosis is: A. hyperthyroidism B. polycythemia C. ABO incompatibility D. opioid withdrawal E. hyperglycemia

B. polycythemia Polycythemia of the newborn is relatively common and involves a central venous hematocrit (Hct) level of greater than 65%. Blood viscosity increases exponentially as the Hct level rises above 42%. Polycythemia is more common in diabetic mothers, and newborns can present with irritability, tremor, jitteriness, "ruddiness" (red color), and priapism in males. Symptoms generally begin about 2 hours after birth as this is when the hematocrit is the highest due to fluid shifts. Symptoms attributed to this disorder are felt secondary to increased blood viscosity and decreased perfusion. The most common cause is delayed clamping of the umbilical cord with increased placental transfer of blood to the newborn. A second cause is increased intrauterine erythropoiesis due to chronic intrauterine hypoxia. This can be seen with preeclampsia or any hypertensive or vascular disorder that affects placental blood flow. Other causes would include cardiac disorders, pulmonary disorders, high altitude or smoking. Treatment is a partial exchange transfusion (PET) using an umbilical venous catheter to reduce the central Hct level.

A 14-year-old female with no past medical history presents to your office with the complaint of right eye photophobia, tearing, and pain. She states she feels like there is something stuck in her eye, but she cannot see anything in it. She admits to accidentally rubbing her open eye with a towel this morning while getting ready for school. She wears daily disposable contacts but was not wearing contacts at the time of the incident. Examination with fluorescein dye and a cobalt blue light shows a linear corneal abrasion measuring approximately 1 mm by 3 mm on the inferior cornea. Which of the following, if used alone, would be the best treatment to prescribe? A. topical anesthetic drop B. topical antibiotic ointment C. topical lubricant ointment D. topical miotic drop E. topical steroid drop

B. topical antibiotic ointment Corneal abrasions can either be considered traumatic or spontaneous. Spontaneous defects in the corneal epithelium may occur with no injury or foreign body. Patients who have suffered a corneal abrasion in the past are more at risk for a corneal abrasion. Corneal abrasion must be suspected in any patient who complains of photophobia and/or foreign body sensation, but penetrating trauma and infectious infiltrate must be ruled out. History of being a contact wearer is important in making treatment decisions.Administration of antibiotics is the mainstay of therapy. The purpose of the antibiotic therapy is to prevent superinfection. While it is the most common treatment, there is not good evidence regarding whether topical antibiotics prevent infection or shorten the time to healing. Ointments are preferred over drops because they function better as lubricants.Non-contact lens wearers should be treated with ophthalmic erythromycin or bacitracin. Contact lens wearers are treated with antipseudomonal coverage such as an aminoglycoside or fluoroquinolone. Antibiotic preparations containing steroids are contraindicated because they slow epithelial healing and reduce host resistance to superinfection.Patching the eye should be avoided in small abrasions and is contradicted in contact lens wearers secondary to vegetative matter. Patching may decrease the pain of large corneal abrasions that cover >50% of the corneal surface.The corneal epithelium usually heals within 48 to 72 hours.

In ------ metaplastic simple columnar epithelium replaces the stratified squamous epithelium.

Barrett's esophagus This patient presents with concerns of Gastroesophageal reflux disease (GERD). Often there is concerns that GERD may progress to Barrett's esophagus. Barrett's esophagus occurs with chronic GERD. When this occurs, metaplastic simple columnar epithelium replaces the stratified squamous epithelium that normally lines the distal esophagus. Since the doctor saw normal epithelium while performing the endoscopy, stratified squamous endothelium would likely have been seen on pathology.Almost all patients with Barrett's esophagus are treated indefinitely with a proton pump inhibitor (PPI). The primary reason for treating acid reflux is that it may lead to chronic esophageal inflammation, which in turn may predispose to cancer development. Annual cancer incidence in patients with Barrett's esophagus have ranged from 0.1 to almost 3.0 percent, but the risk of developing esophageal cancer is increased at least 30-fold above that of the general population.

The most appropriate course of action in this case is to contact the organ donor network. The Uniform Anatomical Gift Act reaffirms that if a donor has gifted organs, her or his wishes should be honored, and the family need not give additional consent. It also expanded the list of people able to consent for organ or tissue donation if a potential donor has not registered her or his wishes before death.

Bottom Line: Contact the organ donor network to obtain consent for organ donation.COMBANK Insight : Nationwide, approximately 30% of all deceased organ donors come from trauma patients. Although a patient's driver's license may state that he or she is an organ donor, the ultimate decision is made by the medical power of attorney as to whether organs are harvested. In any case, the organ donor network should be contacted; the medical team should never approach the family.

----- is an alkylating agent used in the treatment of chronic myeloid leukemia (CML). It can also be used for ablating bone marrow in hematopoietic stem cell transplant patients.

Busulfan

The calcarine sulcus is a landmark located in the occipital lobe and is the location of the primary visual cortex. This area of the brain is responsible for visual reception and interpretation and a lesion of this area would be expected to cause visual disturbances, not a tremor.

true

Obstructive lung disease results in an increased total lung capacity (TLC), functional reserve capacity (FRC), and residual volume (RV). Obstructive lung disease also decreases the forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), and the FEV1/FVC ratio. The pattern differs in restrictive lung disease, which shows decreases in TLC, FVC, RV, FRC, and FEV1 and a normal to slightly elevated ratio of FEV1/FVC.The patient in the above case is suffering from emphysema, and you would expect to find an obstructive pattern on pulmonary function testing. Chronic bronchitis and emphysema are both obstructive lung diseases. Diffusion capacity for carbon monoxide (DLCO) can distinguish between the two. DLCO reflects the ability of oxygen to move from inhaled air to red blood cells across the alveolar-capillary membrane. Classically, diseases that result in the destruction of the alveolar surface area (emphysema) or thickening of the alveolar-capillary membrane (interstitial lung disease) result in a decreased DLCO due to diffusion impairment. Chronic bronchitis results in increased production of mucus and subsequent obstruction without alteration of the alveolar-capillary membrane. Thus, the DLCO would be normal in chronic bronchitis patients. DLCO does not distinguish between obstructive and restrictive lung disease; only other values, such as TLC, can do that.

Bottom Line: Know the differences in pulmonary function testing for both restrictive and obstructive lung disorders. DLCO will be decreased in emphysema and normal in chronic bronchitis.

This patient has clear signs and symptoms concerning for progressive dementia. All patients with symptoms of memory impairment should be evaluated for contributing factors. The diagnostic evaluation of dementia in the elderly includes evaluation for depression, review of all contributing medications, review of the patient's ability to perform ADLs and IADLs, objective assessment of cognitive domains including executive functioning, memory, attention, language, and visuospatial skills, and a detailed neurological exam to assess for focal deficits which may indicate some underlying neurological disease. Based on the above, this patient should have a medication review to evaluate for contributing medications. Common medications which may worsen or produce signs of cognitive impairment include anticholinergics and opiates. This patient should also have a cognitive assessment using some kind of verified screening tool such as the Montreal Cognitive Assessment (MoCA) or the Mini-Cog. Alternatively, a short screening test could be performed using the General Practitioner Assessment of Cognition (GPCOG) or Memory Impairment Screen (MI) and if positive, proceed to a longer tool such as the MoCA. Additionally, given his complaints, he should be screened for depression and if positive, evaluated, and treated accordingly. If there are focal neurological deficits, then some kind of brain imaging is needed to rule out structural abnormalities which may be contributing.CT and MRI of the brain are generally used as adjuncts to the diagnosis of dementia when there is a concern for some organic, underlying process. They should be strongly considered if there are focal neurological findings, rapidly progressive or sudden onset dementia, young age of onset (< 65), or there is a history of significant head trauma. This patient has new onset dementia after the death of his wife, and some kind of brain imaging could be obtained given the sudden onset and severity.

Bottom Line: Memory impairment should be assessed with a good history, cognitive screening tool, depression screen, medication review, and detailed neurological exam.

Secondary hypertension females of reproductive age.

Bottom Line: Oral contraception is a prevalent and often overlooked cause of hypertension in females of reproductive age. Discontinue oral contraceptives in a young female with hypertension, but make sure you discuss other contraception options prior to making this decision.COMBANK Insight : The COMLEX examination will provide you with the information necessary to answer the question appropriately. This is unlike the USMLE, which will throw in distracting information that you must dissect through to come to the correct diagnosis. COMLEX may provide answer choices for this question such as smoking cessation, discontinue oral contraceptives, weight loss, or begin an antihypertensive medication. In the case of a young female with hypertension, always discontinue oral contraceptives first. Secondary hypertension is defined as elevated blood pressure due to a specific cause, such as smoking, excessive alcohol use, obesity, renovascular hypertension, or use of specific medications. In a young female on oral contraceptives, discontinuation of the contraceptive should be the initial step in the management of hypertension. Other important management options include smoking cessation and weight loss, which would help decrease blood pressure as well. Secondary hypertension is commonly caused by oral contraception, which is thought to be caused by an estrogen-mediated increase in liver angiotensinogen production. It is important to recognize that oral contraceptives should be discontinued prior to initiating antihypertensive therapy, especially in young females.

This case is consistent with pre-term premature rupture of membranes (PPROM) complicated by an infection. The sudden loss of fluid (gush of fluid) is a very specific sign. Oligohydramnios is a common finding associated with PPROM. Do not confuse PPROM with PROM, which is premature rupture of membranes.

Bottom Line: PPROM is associated with oligohydramnios. The most common infection associated with PPROM is chorioamnionitis, not endometritis. Endometritis is a common post delivery infection associated with a complicated delivery. Labor should be induced immediately in patients with PPROM and evidence of intrauterine infection, placental abruption, or evidence of fetal compromise. IV antibiotics are indicated in patients with evidence of intrauterine infection.

Weight loss, dull chronic epigastric pain, and jaundice in a middle-aged male should always be concerning for pancreatic cancer. There is some disagreement about the best initial test, depending on the patient being studied. If there is concern for some kind of obstructive process within the common bile duct which is not cancer (e.g., there is concern for choledocholithiasis), then it is reasonable to start with a right-upper-quadrant (RUQ) ultrasound to evaluate the biliary tract. This can often identify large pancreatic head tumors, but it is also susceptible to bowel gas obstructing the view of the pancreas. Ultrasound (US) will be unable to delineate vascular involvement or metastasis and is generally considered inferior to the CT pancreas protocol for initial evaluation if there is no concern for more acute biliary obstruction.In this patient with chronic pain and normal vitals, there is no concern for acute choledocolithiasis, and a CT pancreas protocol should be obtained. He has numerous risk factors for pancreatic cancer and a classic presentation. He also has a negative EGD one month ago and no history of pancreatitis. If a mass is found, generally most patients will proceed to endoscopic ultrasound (EUS) or ERCP for biopsy, depending on the location of the mass and local expertise.

Bottom Line: The best initial test for detecting pancreatic cancer is a CT scan of the pancreas. COMBANK Insight : Patients typically report the gradual onset of nonspecific symptoms such as anorexia, malaise, nausea, fatigue, and midepigastric or back pain. Significant weight loss is a characteristic feature of pancreatic cancer. Painless jaundice and a palpable gallbladder indicate pancreatic cancer until proven otherwise. CA 19-9 is not sensitive enough for early detection, but it may be elevated with large or metastatic cancers. There are also a fair number of false positives due to other causes of biliary/pancreatic inflammation. This tumor marker can be used to monitor treatment. Once the diagnosis of pancreatic cancer is made, a baseline CA 19-9 should be measured and monitored with chemotherapy or after resection.

Arterial insufficiency is due to a lack of blood flow. This creates the symptoms of claudication due to a muscle ischemia. Physical signs of arterial insufficiency are hair loss, toenail thickening, and calf atrophy.

COMBANK Insight : This patient finds relief by resting the leg off the side of the bed, creating an increase in blood flow by increasing dependent flow to the leg.

Acute bronchitis is caused by inflammation of the trachea and bronchi due to infection of the upper respiratory tract or exposure to inhaled irritants. It presents in a much more acute setting with signs and symptoms of productive cough, sore throat, fever, wheezing, and tight breath sounds. Treatment is usually supportive.

Answer D: Patients with chronic bronchitis would be expected to present with productive cough, progressing over months. These patients may also suffer from frequent and recurrent pulmonary infections, and progressive cardiopulmonary failure may also be present due to the development of pulmonary hypertension and cor pulmonale.

This patient is demonstrating the classic signs and symptoms of bulimia nervosa. Bulimia nervosa is typically seen in young females who are average to slightly above average weight who present with dizziness, muscle weakness, and cramping during exercise. On physical examination, signs of volume depletion may be noted. Perimolysis (erosion of the tooth enamel) and enlargement of the parotid glands and tonsils (secondary to vomiting) carry a high index of suspicion for bulimia over other conditions. Bulimia nervosa is managed with selective serotonin reuptake inhibitors as well as cognitive behavioral therapy and/or psychotherapy.

Bottom Line: The classic presentation of bulimia nervosa is a female of average to above average weight, who presents with dizziness, dehydration, muscle weakness, and erosion of the tooth enamel on physical examination.COMBANK Insight : Eating disorders are heavily tested on COMLEX and almost always show up in some form. Pay attention to the details in the case to distinguish between anorexia and bulimia and know the characteristic features of both disorders. If a patient presents with symptoms such as refusal to eat, with no evidence of binging and purging, but NORMAL body weight - this is bulimia. Anorexia nervosa requires low body weight as criteria for diagnosis.

The lung nodule in this scenario is low risk based on the pattern of calcification and smooth contours. A 1.5-cm nodule with low-risk features should be followed up in 3 months with a computed tomography (CT) scan of the chest. If the lesion has high-risk features, tissue sampling would be appropriate. In general, characteristics favoring a benign lesion include no smoking history, lesion stability, small size, smooth margins with uniform shape, and certain patterns of calcification (concentric calcification is a benign pattern). The Fleischner Society has published recommendations for the management of lung nodules incidentally found on CT of the chest. The patient must be >35 years old and not immunocompromised. In this case, the patient is "low risk" per the Fleischner criteria and should have a follow-up chest CT in 3 months.A Chapman point represents the somatic manifestation of a visceral dysfunction. Most posterior Chapman reflex points are located between the spinous and transverse processes; they have a rubbery texture when palpated. The Chapman reflex points related to the right upper and lower lungs are located at the right T3 and T4 intertransverse spaces, respectively. Once a Chapman point is localized, firm pressure is applied to the point. Pressure is applied in a circular pattern with an attempt to flatten the mass, and this is continued until the lesion is resolved or the patient can no longer tolerate treatment.

Bottom Line: This patient's nodule meets criteria for computed tomography follow-up based on the Fleischner Society's guidelines. COMBANK Insight : When presented with a pulmonary nodule, always remember to compare it to prior imaging to note any change in appearance. This is an easy step but is often missed on exams. After comparing films, then move to a computed tomography scan to determine the location, progression, and size of the lesion. This will often help you to distinguish between benign and malignant lesions.

The most serious concern in postmenopausal women with abnormal uterine bleeding is endometrial carcinoma. Of all postmenopausal women with bleeding, 5 to 10 percent are found to have endometrial carcinoma. Thus, in this age group, endometrial biopsy or transvaginal ultrasonography is included in the initial investigation. Other causes of postmenopausal vaginal bleeding include: Polyps--These are growths, usually noncancerous, that can develop in the uterus, on the cervix, or inside the cervical canal. They might cause bleeding. Endometrial atrophy (thinning of the endometrium)--The endometrium, the tissue that lines the uterus, can become very thin after menopause because of lower estrogen levels. This may cause unexpected bleeding. Endometrial hyperplasia--In this condition, the lining of the uterus becomes thick, and bleeding may occur as a result. Obesity may be the cause of the problem. Some people with endometrial hyperplasia may have abnormal cells that can lead to endometrial cancer (cancer of the uterine lining). Endometrial cancer (uterine cancer)--Bleeding after menopause can be a sign of endometrial cancer. Other causes--Hormone therapy, infection of the uterus or cervix, use of certain medications such as blood thinners, and other types of cancer can cause postmenopausal bleeding.

Bottom Line: Uterine pathology, particularly endometrial carcinoma, is common in postmenopausal women with abnormal uterine bleeding. Thus, in this age group, endometrial biopsy or transvaginal ultrasonography is included in the initial investigation.COMBANK Insight : In postmenopausal women with unexpected uterine bleeding, they should be first evaluated for endometrial carcinoma, which is a potentially lethal disease and the cause of bleeding in approximately 10 percent (range 1 to 25 percent, depending upon risk factors). However, the most common cause of bleeding in these women is atrophy of the vaginal mucosa or endometrium.

This patient presents with a malabsorption syndrome (cramps, bloating, loose and foul-smelling stool). The loss of night vision indicates vitamin A deficiency, which is consistent with malabsorption. The combination of malabsorption with joint pain is most likely Whipple disease. This disease is caused by a gram-positive bacterium and can be diagnosed with a biopsy. Oculomasticatory myorhythmia (OMM), which involves pendular vergence oscillations of the eyes and synchronous contractions of the masticatory but not palatal muscles, is pathognomonic of Whipple disease.

Bottom Line: Whipple disease is a systemic gram-positive bacterial infection that commonly manifests as malabsorption, joint pain, and central nervous system symptoms. versus Pernicious anemia can be caused by antibodies to intrinsic factor. It leads to vitamin B12 deficiency.

This is an example of a contaminated wound. The definition of a contaminated wound is one in which a hollow viscous is entered and there is gross contamination of the surgical field from the contents of the hollow viscous. Included in this category are wounds with visible signs of infection, including purulent fluid, phlegmon, and fibrinous exudate.

CONTAMINATED WOUND

Bluish discoloration of the cervix and vagina is one of the earliest signs of pregnancy and is referred to as ----

Chadwick's sign. During early pregnancy, several physiologic changes are noted. It is typical for the vagina and cervix to turn bluish in color, which is referred to as Chadwick's sign. Common early signs of pregnancy include the following:Chadwick's sign: Bluish discoloration of the vagina and cervixGoodell's sign: Softening and cyanosis of the cervix at, or after, 4 weeks' gestationLadin's sign: Softening of the uterus after 6 weeks' gestation

A 52-year-old man is reported to authorities for rubbing his genitalia on multiple women while on the subway. This behavior can also be referred to as: A. Exhibitionism B. Fetishism C. Frotteurism D. Necrophilia E. Voyeurism

C-Frotteurism is demonstrated by rubbing one's genitalia against another person who is not consenting and unaware of the event. Such occurrence is present in this case, where the male is rubbing his genitalia on women on the subway. Voyeurism refers to individuals who gain pleasure from watching other people undress or engage in sexual activity.--Necrophilia occurs when one gets sexual pleasure from engaging in sexual activity with dead bodies.--Fetishism describes the act of using inanimate objects for sexual pleasure.--Exhibitionism occurs when one reveals his or her genitals to unsuspecting people for shock value.--

A 12-year-old male with well-controlled type I diabetes is involved in a motor vehicle accident and presents to the emergency department via ambulance. An X-ray reveals a closed fracture of the left tibia showing minimal displacement. The patient is placed in a cast in the emergency room and discharged. One day later, the boy presents to the emergency department because of increased pain. He has pain out of proportion with passive extension of his great toe. What is the most likely diagnosis? A. Diabetic neuropathy B. Compression neuropathy C. Compartment syndrome D. Normal progression E. Neuropraxia

C. Compartment syndrome Any time a cast is applied, a complete neurovascular exam must be completed and documented to ensure that it is not too tight. Compartment syndrome is a must-know subject for COMLEX. The six P's are pain, paraesthesias, pallor, paralysis, poikilothermia, and pulselessness. Due the high-energy mechanism, one should be suspicious for compartment syndrome. The patient has pain out of proportion to exam. This is one of the first signs of compartment syndrome. The six P's of compartment syndrome are pain, paraesthesias, pallor, paralysis, poikilothermia, and pulselessness. Loss of pulses is a very late sign. After placing any form of splint or cast, a neurovascular exam needs to be completed to ensure that the cast isn't too tight. In this situation, compartment syndrome could be from a poorly fitted cast or the tibia shaft fracture.

A 62-year-old male presents to the Emergency Department after experiencing symptoms of substernal chest pain, malaise, weakness, and arthralgias. He brings discharge records which reveal that he was treated for an acute inferior myocardial infarction two weeks ago. Physical examination is significant for both pericardial and pleural friction rubs. He is found to have a temperature of 102°F. The most likely diagnosis is A. Acute inferior wall myocardial infarction B. Aortic dissection C. Dressler syndrome D. Post-infarction pericarditis E. Pulmonary embolism

C. Dressler syndrome Bottom Line: Dressler, or postpericardiotomy syndrome is a post-infarction disorder thought to have an autoimmune etiology which occurs up to 28 weeks post-infarction (peak onset between 2 and 4 weeks) and typically presents with chest pain and constitutional symptoms.COMBANK Insight : This is a tricky question. If you're not careful, you could make the diagnosis of post-infarction pericarditis. The COMLEX has a lot of questions that appear to have multiple right answer choices. There are usually details in the stem that provide clues to the right answer. In the above case, the onset of symptoms is the key to making the correct diagnosis.

----- presents with thick, clumpy, white, cottage cheese-like discharge. A potassium hydroxide (KOH) wet mount will reveal pseudohyphae, and pH will be 3.5-4.5. Treatment is an antifungal including topical clotrimazole or oral fluconazole. Patients typically have a history of diabetes, had recent antibiotic treatment, or are pregnant.

C. albicans

A 45-year-old female with a history of hypertension, anxiety, and epilepsy presents to the emergency department with complaints of headache, increased light and sound sensitivity, sweating, and hand tremor. She states her anxiety is "through the roof" and she feels like she is having a panic attack. Patient denies any past medical history of tobacco use, alcohol use, or illicit substance use. Her current medications include a selective serotonin reuptake inhibitor, a beta-blocker, and one other medication that she has forgotten to refill recently. A. alcohol B. cocaine C. diazepam D. morphine E. phenobarbital

C. diazepam This patient is experiencing withdrawal from benzodiazepines (BZD). Although selective serotonin reuptake inhibitors (SSRIs) are recommended for chronic long-term use in the treatment of anxiety, many patients remain on as-needed or scheduled benzodiazepines. In the case of an abrupt or precipitously rapid reduction in BZD dosing, withdrawal can occur. It is important to recognize the signs and symptoms of benzodiazepine withdrawal as it can be a life-threatening condition, especially given this patient's history of epilepsy. Patients may present with tremors, anxiety, perceptual disturbances such as phonophobia or photophobia, dysphoria, psychosis, and seizures. Onset of withdrawal is typically related to the half-life of the particular drug. A patient taking BZDs with a long half-life may not have symptoms until 3 weeks after discontinuation of the medication. On the other hand, symptoms may appear as soon as 24 to 48 hours after discontinuation of those with short half-lives. Management of withdrawal is with a BZD that has a long clinical effect such as diazepam.

A 63-year-old patient presents to the clinic after a recent hospitalization for her severe chronic obstructive pulmonary disease (COPD). She has additional past medical history of hypertension, which started about 10 years ago. She tells you that she feels so unlucky because even though she was never a smoker, she ended up with COPD and has been in and out of the hospital for decades. On exam, you notice purple striae on her abdomen and central obesity with thin arms and legs. She states that those purple lines and her "big belly" have been there "for a while." She is now, however, complaining of new frequent thirst and urination. The most likely etiology of the patient's findings is A. adrenal cance B. ectopic adrenocorticotropic hormone production from small-cell lung cancer C. iatrogenic D. pituitary adenoma E. primary adrenal hyperplasia

C. iatrogenic This patient likely has hypercortisolism. The most common cause of hypercortisolism is Cushing syndrome. Cushing syndrome is a metabolic disorder caused by overproduction of corticosteroid hormones by the adrenal cortex. Chronic hypercortisolism inhibits hypothalamic corticotropin-releasing hormone (CRH), vasopressin secretion, and adrenocorticotropic hormone (ACTH) secretion by normal pituitary corticotrophs. The most common cause of Cushing syndrome is iatrogenic Cushing due to exogenous administration of glucocorticoids. The second most common cause overall is Cushing disease (pituitary hypersecretion of ACTH). Other causes include adrenal adenomas or hyperplasia. The symptoms present in this patient are likely due to chronic steroids used to treat her chronic obstructive pulmonary disease. Common symptoms of Cushing syndrome include decreased libido, central obesity/weight gain, round face, hirsutism, hypertension, ecchymoses, lethargy, depression, and abnormal glucose tolerance. Other symptoms include striae, acne, and edema. Treatment should be focused at the primary source of the excess corticosteroid hormones.

Which of the following deficits would be expected with injury to the anterior interosseous nerve? A. inability to abduct the radiocarpal joint B. inability to extend the thumb interphalangeal joint C. inability to flex the thumb interphalangeal joint D. loss of sensation over the dorsal aspect of the little finger E. loss of sensation over the palmar aspect of the thumb

C. inability to flex the thumb interphalangeal joint

A 25-year-old male presents to the emergency department for odd behavior. When you approach him, he anxiously asks you why there are so many monkeys running around the emergency department. Vital signs reveal a blood pressure of 169/101 mmHg, a heart rate of 112/min, and respiratory rate of 21/min. His girlfriend tells you that he is a chronic drug abuser who recently abruptly stopped his drug habits 2 days ago in attempt to become sober. She says she does not know what drug he uses as he has abused various drugs in the past. The most likely etiologic agent is one that has which effect? A. decreases glutamate receptor conductance B. increases cannabinoid receptor conductance C. increases gamma-aminobutyric acid conductance D. increases nicotinic receptor conductance E. increases opioid receptor conductance

C. increases gamma-aminobutyric acid conductance This patient is presenting with a classic case of acute benzodiazepine withdrawal. Benzodiazepines work by modifying gamma-aminobutyric acid (GABA) receptors to increase conductance of this inhibitory channel. Benzodiazepines are commonly used for the treatment of seizures, anxiety, alcohol withdrawal, insomnia, and control of drug-associated agitation and as muscle relaxers and preanesthetic agents. Because of their common use and availability, they have a propensity for abuse. There is a synergistic effect when combined with alcohol. Symptoms of intoxication include amnesia, ataxia, somnolence, and respiratory depression. Flumazenil can be used as an antidote for acute intoxication. As with most withdrawal syndromes, symptoms are similar to what benzodiazepines are used to treat, including anxiety, seizures, auditory or visual hallucinations, and insomnia. Physical exam findings are related to autonomic hyperactivity and include hypertension and tachycardia. Untreated benzodiazepine withdrawal can result in death.

A 11-year-old is brought by his mother to an urgent care clinic for care of an acutely red eye. He awoke this morning with his left eye matted shut by a purulent discharge and crusting at the eyelashes. He attends school five days a week. His mother has given him acetaminophen for pain, but he continues to complain of pain though he is afebrile. Extra-ocular movements are intact. On osteopathic examination, the greater wing of the sphenoid feels more superior on the right than on the left. Additionally, the occiput is rotated in the opposite direction. The most appropriate pharmacologic treatment for this condition is: A. ophthalmic antihistamines B. ophthalmic corticosteroids C. ophthalmic fluoroquinolone D. oral antihistamines E. oral penicillin

C. ophthalmic fluoroquinolone This patient is presenting with a case of conjunctivitis, as illustrated by his symptoms of red eye, eye pain, and crusting at the eyelashes. Most cases of conjunctivitis are viral in origin, presenting with yellow crusting near the eyelashes. Bacterial conjunctivitis is less common and presents with purulent discharge, as indicated in this case. Although the most common etiology of conjunctivitis is viral, bacterial super-infections are fairly common and therefore many practitioners will treat prophylactically for bacterial infections as well. Topical fluoroquinolones are one of the several options for topical antibiotics that will treat the most common causes of bacterial conjunctivitis. It is a good idea in this age group to treat both eyes, because the condition is very contagious and will often be transmitted to the opposite eye.

A dermoid cyst is a type of cystic teratoma that contains developmentally mature skin complete with hair follicles and sweat glands, sometimes clumps of long hair, and often pockets of sebum, blood, fat, bone, nails, teeth, eyes, cartilage, and thyroid tissue. The presence of these tissue types makes this diagnosis unique.

true

A 23-year-old G1P1 female presents to her gynecologist with symptoms of waxing and waning pelvic pain. She had a copper intrauterine device placed about 16 months ago after the birth of her first child. She states she was having regular menstrual cycles until about 2 months ago, at which time she stopped having regular periods. Her pelvic pain is crampy in nature and started about the same time. A pelvic speculum examination is performed, which reveals the absence of the intrauterine device strings. The most appropriate next step in the management of this patient is A. laboratory evaluation for thyroid-stimulating hormone, free thyroxine, prolactin, and follicle-stimulating hormone for workup of her secondary amenorrhea B. obtain cultures and treat for presumed infected intrauterine device C. perform a pregnancy test D. schedule the patient for diagnostic laparoscopy and removal of foreign body E. ultrasound examination to look for a misplaced intrauterine device

C. perform a pregnancy test This patient was having regular cycles with her intrauterine device (IUD) in place until about 2 months ago. At that time, her cycles suddenly ceased. One of the first steps in the workup of amenorrhea in a woman of childbearing age is to perform a pregnancy test. This is even more important when the strings of the IUD cannot be visualized. It is possible that the IUD was never in the appropriate location. It is also possible that the IUD was expelled without the patient's knowledge. Further, given the timing, it is possible that the IUD is still in the uterus and she became pregnant with it in place. When this occurs, as the uterus enlarges, the IUD strings get pulled into the uterus and are unable to be visualized in the cervix. When this situation occurs, the protocol is to leave the IUD in place for the duration of the pregnancy. If the scenario arises in which a woman finds out she is pregnant with an IUD in place and the strings are still visualized, the protocol is to remove the IUD gently and expectantly monitor the pregnancy.

A 52-year-old female presents to the Emergency Department experiencing sudden and complete loss of vision in her left eye. While obtaining a history, she states that her vision has now returned, and that she must have "just been tired from the long car ride back from the camping trip." The vision loss is described as painless. The event lasted approximately five minutes before spontaneous resolution. Physical examination and vital signs are unremarkable. Somatic dysfunction is noted between T1-T4 on the left. Laboratory studies are unremarkable. The most likely cause of this patient's symptoms is A. infiltration of medium and large sized arteries by mononuclear cells B. pathologic demyelination of the opthalmic division of the fifth cranial nerve C. plaque destabilization and downstream embolism to the ophthalmic artery D. embolism from the atrial appendage into the middle cerebral artery E. near complete occlusion of the ipsilateral carotid artery

C. plaque destabilization and downstream embolism to the ophthalmic artery Transient ischemic attacks (TIAs) are brief episodes of stroke symptoms, including hemiplegia, facial droop or slurred speech, numbness, reduction in sensory or vibratory sensation, etc. The history and physical exam is suggestive of TIA. The standard definition of duration is less than 24 hours, but most TIAs last only 10-15 minutes, and the new definition states that the symptoms should resolve with no evidence of ischemia (negative MRI). TIAs most commonly arise from emboli to the brain or from in situ thrombosis of a vessel. With a TIA, the occluded blood vessel reopens and neurologic function is restored with no residual neurologic deficits. Amaurosis fugax, or transient monocular blindness, occurs from emboli to the central retinal artery of one eye. The most common pathway is plaque destabilization from the carotid artery leading to downstream embolism.

A 35-year-old female has missed several primary care appointments over the past 2 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 prescription, the physician decides to dismiss the patient from the practice. What obligation does the physician have to this patient? A. the physician must contact the patient by telephone to formally state that they are terminated B. the physician must find a new primary care physician for the patient C. the physician must provide copies of all patient paperwork if requested D. the physician must provide free care to the patient for 2 weeks until termination is complete E. the physician must submit paperwork to the state medical board stating the reason for termination

C. the physician 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 and 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 prepaid health plan. When dismissing a patient from practice, the physician must provide transfer records to the newly designated physician upon signed patient authorization to do so.

C? corresponds with innervation to the respiratory diaphragm and sensation to the upper shoulder region.

C4 corresponds with innervation to the respiratory diaphragm and sensation to the upper shoulder region.

Bottom Line: C5 nerve root level impingement can cause paresthesias in the lateral upper arm with shoulder and elbow flexion weakness as well as a diminished biceps deep tendon reflexes.

C5 nerve This patient presents with symptoms consistent with C5 nerve root impingement. The C5 dermatome is located along the proximal lateral arm to the proximal forearm. Muscles with C5 innervation will exhibit weakness; this includes the deltoid, supraspinatus, infraspinatus, pectoralis major and minor, coracobrachialis, and biceps muscles. The biceps tendon deep tendon reflex (DTR) is often reduced in a C5 nerve root impingement. Treatment options are often predicated on the severity of the nerve root impingement. Mild impingements are often treated conservatively with rest and physical therapy to the neck and arms, while severe impingements with significant denervation or associated cervical instability require surgical considerations.

C? corresponds to the brachioradialis DTR, provides motor innervation to the brachialis and wrist extensors, and provides sensation to the lateral forearm and first 2 digits.

C6 corresponds to the brachioradialis DTR, provides motor innervation to the brachialis and wrist extensors, and provides sensation to the lateral forearm and first 2 digits.

C? has no DTR, provides motor innervation to the finger flexors and intrinsic hand muscles, and provides sensation to the medial forearm and fifth digit.

C8 has no DTR, provides motor innervation to the finger flexors and intrinsic hand muscles, and provides sensation to the medial forearm and fifth digit.

A CAM boot is rarely necessary in plantar fasciitis. It unloads the foot and helps patients to walk with less pain. It would be an appropriate treatment if this patient had a stress fracture.

CAM=Controlled ankle movement boot

Bottom Line: Trachoma should be suspected in cases of non-resolving conjunctivitis from third-world countries, where it remains endemic. It is treated with azithromycin 1g in a single dose.

Chlamydia trachomatis often presents with mucopurulent discharge, redness, tearing, and foreign body sensation. It is often spread through direct hand-to-hand contact with infected secretions. The patient in this case could have contracted it through contact with either unwashed clothing or direct contract with secretions. Sometimes, it is spread by contact with flies that can spread secretions person to person. It is most often spread by children and poor hand-washing practices. Follicles develop on the tarsal conjunctival of the upper eyelid and lead to corneal irritation and eventual scarring. This can lead to blindness and ectropion. Trachoma is caused by an obligate intracellular organism, Chlamydia trachomatis, specifically serotypes A-C. The infectious form is found as an elementary body and the replicating form is known as the reticulate body. Diagnosis can be made by Giemsa stain and cell culture; however, in the modern era, diagnosis is now most often obtained by nucleic acid amplification testing (NAAT). Both gonococcus and chlamydia can be tested in this way, through either urethral swab, urine, or vaginal discharge collection. NAAT can also be attempted on rectal and oropharyngeal swabs; however, it is not specifically approved for those types of fluid. Treatment of adult genital and ocular chlamydia consists of azithromycin 1g orally in a single dose. Because chlamydia is an obligate intracellular pathogen, it must be grown in culture with living cells and is therefore notoriously difficult to grow and stain. Pure gram stain would generally be negative, as opposed to gonorrhea, which is a gram negative diplococcus and should grow on chocolate agar. If this patient had gonorrheal infection of the eye, the gram stain would be positive. In both cases, NAAT would also be positive. Chlamydia trachomatis is the most common cause of bacterial sexually transmitted infection (STI) in both men and women. In the United States, it is the most commonly reported nationally notifiable disease. A significant proportion of patients are asymptomatic, thereby providing an ongoing reservoir for infection. The most frequent clinical manifestation of chlamydial infection in men is urethritis, while the most common finding in women is cervicitis. Trachoma is a contagious eye infection caused by Chlamydia trachomatis and is the leading infectious cause of blindness worldwide. C. trachomatis is transmitted by intimate social or sexual contact. Serotypes A, B, Ba, and C cause trachoma, serotypes D to K cause genital tract infection, and lymphogranuloma venereum is caused by serovars L1-L3.

? Neoplasm commonly presents with asymptomatic leukocytosis with white blood cell (WBC) counts greater than 50,000; typically seen in males over the age of 65 and there is a high incidence among whites; most patients present asymptomatically and it is found through blood work. Some patients may present with painless lymphadenopathy. As disease progresses, patients may develop lymphadenopathy, spleneomegaly, hepatomegaly, anemia, and recurrent infections. 5-10% of patients may present with B symptoms, which include unintentional weight loss>10% of body weight within the previous 6 months, fevers of>38 for >2 weeks without evidence of infection, drenching night sweats without evidence of infection, and extreme fatigue. smudge cells are typically found on the blood smear. therapy is indicated for patients when they have advanced-stage disease, high tumor burden, severe disease-related B symptoms, or repeated infections. Goals of treatment include ameliorating symptoms and improving progression-free and overall survival. there is no current treatment that is a cure.

Chronic Lymphocytic Leukemia

The patient in this case meets the criteria for brain death and should be removed from the ventilator. Clinical criteria for brain death include loss of brainstem reflexes (ie, loss of pupillary light reflex, lack of nystagmus with caloric testing, absent oculocephalic reflex, absent corneal reflex, and the failure to take spontaneous respirations). Brain death is a clinical diagnosis, and although electroencephalogram (EEG) is helpful in confirming brain death, it is not required for diagnosis. The combination of cessation of spontaneous breathing with absent brainstem reflexes is more important than EEG findings. Brain death should be determined by 2 physicians prior to removing the patient from the ventilator.

Clinical criteria for brain death include the absence of spontaneous ventilations coupled with loss of brainstem activity and warrant removal of life-sustaining interventions such as mechanical ventilation if no documentation exists suggesting the patient (or family) wished otherwise. These questions can appear easy on the COMLEX, but be careful to take each clinical scenario into context before making decisions regarding "end of life" care. For example, if family or caregivers are present, always discuss options with them before making drastic decisions (such as pulling the endotracheal tube). Answer choices using words such as "discuss" and "communicate" are usually correct in these circumstances. Also, make sure there is no reason to suspect other etiologies that may mimic brain death, such as barbiturate toxicity or encephalitis, and that may be reversible; in these patients, err on the side of caution.

---------are unknown factors that confuse the true relationship between an exposure and an outcome.

Confounding variables

A new biomedical startup is trying to find a better way to diagnose melanoma from a punch biopsy. Currently, pathologists manually review slides from the biopsy to determine if cancer cells are present. The startup engineers have programmed a computer algorithm to recognize the patterns that correlate with cancer, and they hope that this will mean samples can be rapidly and accurately analyzed automatically. The startup believes this new tool will also help save money and time. To prove that the algorithm is both valid and reliable, they have it analyze different slides from the same patients multiple times. They then compare the computer diagnoses to those of human pathologists, which is the current gold standard. Which of the following is true regarding the validity and reliability of this new computer algorithm? A. A computer algorithm that behaves the same way each time is more likely to be valid than a group of human pathologists B. To be a valid test, the computer must reproducibly diagnose melanoma in multiple samples from the same patient C. To be a reliable test, the computer must have a high rate of agreement with the pathologist D. Reliability can only be estimated with reference to a gold standard E. Validity is the ability of the algorithm to tell which patients have melanoma and which do not50.8% of Users Answered Correctly Rate this Question

Correct answer is below D. D. Reliability can only be estimated with reference to a gold standard This question asks you to understand the difference between validity and reliability. Reliability is a measurement of the consistency of the results. To be reliable, a test does not have to be accurate: it just has to be reproducible. For the test described here, reliability means the computer needs, on the second sample, to come up with the same diagnosis as on the first sample. Validity is the extent to which a test accurately measures a concept; or, for clinical screening tests, the extent to which the test can accurately diagnose the disease in question. For this new algorithm, validity means being able to accurately diagnose melanoma. The diagram below illustrates the difference between validity and reliability, and the important concept that a test can be highly reliable, but not valid.

A 23-year-old female with no prior medical care presents with recurrent right upper quadrant pain and jaundice. She does not know her family history. She does not use alcohol and has never smoked tobacco. Physical exam reveals scleral icterus. The patient has an elevated alkaline phosphatase and markedly abnormal bilirubin with otherwise normal liver chemistry. Ultrasound of the liver shows common bile duct dilation. She undergoes a magnetic resonance cholangiopancreatography, which demonstrates fusiform dilation of the extrahepatic biliary tree. The most likely etiology is A. cholangiocarcinoma B. choledochal cyst C. choledocholithiasis D. chronic pancreatitis with distal common bile duct stricture E. primary sclerosing cholangitis

Correct answer: B B. choledochal cyst In adults, abdominal pain and recurrent cholangitis are the most common presentation of acholedochal cyst. There are 6 types of choledochal cysts (listed below). The patient has a type I cyst with a classic fusiform dilation of the common bile duct. The abdominal pain is usually in the right upper quadrant, and many patients have gallstones either in the cyst or the gallbladder. Magnetic resonance cholangiopancreatography has become the diagnostic procedure of choice. Choledochal cysts have an increased risk of malignancy. The risk increases with age. It is recommended to have surgical removal of the cyst to prevent the development of malignancy. The 6 types of choledochal cysts are as follows: Type I: Fusiform dilation of the common bile duct. Treatment is complete cyst excision with Roux-en-Y hepaticojejunostomy reconstruction. Type II: Simple diverticulum of the extrahepatic biliary tree. Treatment is complete cyst excision and primary closure of the defect with or without placement of a T-tube. Type III:Cystic dilation of the intraduodenal portion of the extrahepatic common bile duct; also known as a choledochocele. Treatment is endoscopic retrograde cholangiopancreatography with endoscopic unroofing of the choledochocele and sphincterotomy of the common bile duct.Type IV:Involves multiple cysts of the intra- and extrahepatic biliary tree. Treatment is resection of the involved segments if possible and Roux-en-Y hepaticojejunostomy. Type V: Isolated intrahepatic biliary cystic disease, also known as Caroli disease. Type VI: Isolated cystic duct cyst. Below are a T1-weighted image (left; dark fluid) and T2-weighted MRI image (right; fluid is bright) showing multiple T1 hypointense/T2 hyperintense regions (arrows) representing dilated bile ducts consistent with Caroli disease (type V).

While training for an upcoming marathon, a 28-year-old athlete comes to your office complaining of tenderness in her ribs and some chest tightness and rib pain when training. Electrocardiogram does not show evidence for cardiac involvement. Physical exam reveals a tenderness along the second rib, which appears to be locked up in inhalation. The most effective treatment for this dysfunction would be You answered this question incorrectly. A. muscle energy to the anterior scalene B. muscle energy to the middle scalene C. muscle energy to the posterior scalene D. muscle energy to the sternocleidomastoid E. rib raising from T3-T6

Correct answer: C The scalenes are secondary muscles of respiration and aid during forceful inhalation. The patient described above has an inhalation rib somatic dysfunction (or an exhalation restriction in older terminology). The posterior scalene attaches to the second rib; therefore, muscle energy to this area would be most useful. Bottom Line:Rib number and their associated muscle attachments that can be used for treatment are noted below:Rib 1: Anterior and middle scalenes Rib 2: Posterior scalene Ribs 3-5: Pectoralis minor Ribs 6-9: Serratus anterior Ribs 10-11: Latissimus dorsi Rib 12: Quadratus lumborum COMBANK Insight :Rib dysfunctions and treatments are typical questions on COMLEX. Knowing muscle attachments and techniques will be high yield.

A 15-year-old male is brought home by some neighbors after being caught beating a stray dog in an alley near his home. He has been known to vandalize the local convenience store and has run away from home twice over the course of the past 3 years. These behaviors are most characteristic of A. antisocial personality disorder B. attention-deficit/hyperactivity disorder C. conduct disorder D. oppositional defiant disorder E. schizoid personality disorder

Correct answer: C-C. conduct disorder Conduct disorder (CD) is one of the most difficult and intractable mental health problems in children and adolescents. CD involves a number of problematic behaviors including oppositional and defiant behaviors and antisocial activities (eg, lying, stealing, running away, physical violence, sexually coercive behaviors). Behaviors used to classify CD fall into the 4 main categories of (1) aggression toward people and animals; (2) destruction of property without aggression toward people or animals; (3) deceitfulness, lying, and theft; and (4) serious violations of rules. CD usually appears in early or middle childhood as oppositional defiant disorder (ODD). Antisocial personality disorder is incorrect because the patient is younger than 18 years old. Antisocial personality disorder patients are also termed sociopaths or psychopaths. Antisocial patients lack empathy and have a disregard for social norms. The patient described in this question might be antisocial once becoming an adult but is not old enough at this time for that diagnosis. ODD is a disorder seen in children that deals with defying authority. It presents at school or at home but does not involve breaking any laws.

Diphtheria is uncommon in the postvaccination era and typically presents in nonvaccinated patients such as immigrant workers and prison inmates as a nonspecific flu-like illness that often progresses to respiratory failure. The presence of a gray pseudomembrane is characteristic of the disease. Cardiac toxicity may result, leading to death. To establish the diagnosis of Corynebacterium diphtheriae, it is vital to both isolate C diphtheriae in culture media and to identify the presence of toxin production. The patient in the above case is suffering from diphtheria, caused by the organism Corynebacterium diphtheriae, which spreads via respiratory droplets, with nasopharyngeal secretions or wound exudates in cases of cutaneous disease. Diphtheria is rarely diagnosed in the United States in the postvaccination era but still appears in nonimmunized parts of the world. Mortality rates in the United States of 30% to 40% have been reported. Initial signs and symptoms are frequently nonspecific and may include sore throat (80% to 90%), low-grade fever (60% to 80%), cervical lymphadenopathy (40% to 50%), malaise, weakness, headache, hoarseness, and other respiratory symptoms. Respiratory failure can quickly occur due to aspiration of the pseudomembrane into the tracheobronchial tree. Cardiac toxicity and the potential for circulatory collapse typically occur 1 to 2 weeks following improvement of pharyngitis. It can manifest as myocarditis (up to 60% of cases), congestive heart failure, ST-T wave abnormalities, or dysrhythmias.

Corynebacterium diphtheriae is characterized as a nonencapsulated, nonmotile, gram-positive bacillus. Erythromycin and penicillin are both recommended for the treatment of diphtheria. Some studies suggest that erythromycin may be better at eradication of the carrier state. Penicillin is recommended in household contacts who may not comply with the duration of erythromycin treatment.

A forward sacral torsion on a left oblique axis has findings of a right deep sacral sulcus and a left posterior inferolateral angle in the presence of a negative lumbosacral spring test.

true

A 25-year-old male without known medical history presents to the emergency department after escaping from a burning building. He is brought in by paramedics, and a primary survey is performed. Physical examination reveals blistering burn injuries on his entire left upper extremity, entire right lower extremity, chest, and abdomen. His blood pressure is 120/75 mmHg and his only complaint is severe pain. He weighs 50 kg (110.2 lb). The patient complains of 10/10 pain and is treated with 8 mg of morphine, bringing the pain to a tolerable 6/10. Blood pressure is now 100/60 mmHg. Physical exam shows delayed capillary refill and decreased skin turgor. Which of the following is recommended for fluid management in this patient? A) 200X36ML lactated Ringer plus maintenance in 16 hours B) 200 x36 ML lactated Ringer maintenance 24 hours C) 200x45 ML Lactated Ringer plus maintenance in 16 hours D) 200X45ML lactated Ringer plus maintenance in 24 hours E) 2L of 5% dextrose in water for 24 hours

D) 200X45ML lactated Ringer plus maintenance in 24 hours Know how to use the Parkland formula and the rule of 9s to determine fluid replacement and percent body surface affected in victims of second- and third-degree burns. The formula is mL of fluid/24 hours = 4 x body mass (kg) x % body surface affected. The rule of 9s is used to determine % body surface affected where the head and both arms are 9% each and the anterior trunk, back, and both lower extremities are 18% each. This question tests your knowledge of using the Parkland formula for fluid management in patients with second- and third-degree burns. The formula is mL of fluid/24 hours = 4 x body mass (kg) x % body surface affected. In this case it would be 4 x 50 (body mass in kg) x 45 (percentage of body surface affected), or 200 x 45. This formula calculates the fluid needed in addition to maintenance over a 24-hour period. The first half of the fluid should be administered during the first 8 hours and the remaining half administered over the next 16 hours. The rule of 9s is used to determine % body surface affected where the head and both arms are 9% each and the anterior trunk, back, and both lower extremities are 18% each. The patient has one arm (9%), one lower extremity (18%), and his chest and abdomen (18%) involved, giving a total of 9 x 5 = 45%.

An elderly woman presents to the emergency department after accidentally taking a double dose of her "water pill". She is complaining of palpitations, abdominal cramps, nausea and vomiting. An EKG is performed and reveals U waves. The most likely electrolyte abnormality responsible for the patient's symptoms is which of the following? A. Hyperkalemia B. Hypernatremia C. Hypocalcemia D. Hypokalemia E. Hyponatremia

D. Hypokalemia

A 70-year-old male presents to his family doctor with complaints of hearing difficulty. He has noted a progressive loss of hearing for the past 2 years and a 6-month history of occasional vertigo. He works as a librarian and has been having trouble hearing the visitors to the library. He also mentions that he has noticed that his hats have seemed to become tighter on him over the past couple of years. Previous to his recent difficulties with hearing, he has been very healthy. He has no medical history, and his surgical history is only remarkable for an appendectomy when he was 20. He is only taking fish oil and vitamin D with no prescribed medications. On exam, his heart rate is 70/min, and his blood pressure is 124/78 mmHg. Tuning fork exams reveals conductive and sensorineural hearing loss. His neurologic exam is normal. He was referred to an ENT (ear, nose, and throat) surgeon who requested a CT exam of the brain to confirm the diagnosis. What is the most likely diagnosis? A. age-related presbycusis B. ear canal impaction C. Ménière disease D. Paget disease of bone E. vestibular schwannoma

D. Paget disease of bone

A 70-year-old male, who has a documented childhood allergy to penicillin, receives inpatient treatment with doxycycline for the treatment of uncomplicated Borrelia burgdorferi. After two hours, the patient develops a fever, chills, rigor, hypotension, headache, tachycardia, hyperventilation, vasodilation with flushing, and myalgias. What is the likely mechanism of his presentation? A. Antibody-dependent, cell-mediated (ADCC) cytotoxicity B. The host's response to the lipid A component of lipopolysaccharide C. An immunological response to cell-wall lipoteichoic acid D. Reaction to endotoxinlike products released by the death of harmful microorganisms E. Antigen-antibody complex formation, giving rise to an inflammatory response and attraction of leukocytes

D. Reaction to endotoxinlike products released by the death of harmful microorganisms This patient is presenting with the Jarisch-Herxheimer reaction, a reaction to endotoxinlike products released by the death of harmful microorganisms within the body during antibiotic treatment. This patient is presenting with the Jarisch-Herxheimer reaction, a reaction to endotoxinlike products released by the death of harmful microorganisms within the body during antibiotic treatment. This reaction is distinct from bacterial sepsis and can occur after initiation of antibacterials, such as mild silver protein, penicillin, or tetracycline, for the treatment of louse-borne relapsing fever (80%-90% of patients) and in tick-borne relapsing fever (30%-40%). An association has been found between the release of heat-stable proteins from spirochetes and this reaction. Typically, the death of these bacteria and the associated release of endotoxins or lipoproteins occurs faster than the body can remove the substances. It usually manifests within a few hours of the first dose of antibiotic as fever, chills, rigor, hypotension, headache, tachycardia, hyperventilation, vasodilation with flushing, myalgia (muscle pain), exacerbation of skin lesions, and anxiety. The intensity of the reaction indicates the severity of inflammation. Reaction commonly occurs within two hours of drug administration, but it is usually self-limiting. The Jarisch-Herxheimer reaction is classically associated with penicillin treatment of syphilis. The duration in syphilis is normally only a few hours. The reaction is also seen in other diseases caused by spirochetes, such as borreliosis (Lyme disease and tick-borne relapsing fever), leptospirosis, and Q fever. Similar reactions have also been reported to occur in bartonellosis (including cat scratch disease), brucellosis, typhoid fever, trichinosis, and cerebral trypanosomiasis.

A 41-year-old male arrives in the rapid care center after experiencing palpitations for the past several hours. He has a known history of Wolff-Parkinson-White (WPW) syndrome, which had always been asymptomatic in the past. Physical exam demonstrates an irregular heart rhythm, at a rate of 140/min. Blood pressure is 85/45 mmHg. What is the best next step in managing this patient? A. Intravenous (IV) procainamide B. IV verapamil C. Posteroanterior and lateral radiographs of the chest D. Synchronized cardioversion E. Unsynchronized cardioversion

D. Synchronized cardioversion Atrial fibrillation can commonly be seen in association with WPW syndrome. When a patient is hemodynamically unstable, such as in this case with a rapid heart rate and hypotension, cardioversion is generally indicated acutely. However, cardioversion should be avoided if there is a high suspicion of intracardiac thrombus. Answer A: IV procainamide can be used to convert atrial fibrillation to a normal sinus rhythm in a hemodynamically stable patient. However, it is not used in the acute setting with an unstable patient.Answer B: IV verapamil can be used for rate control in hemodynamically stable patients with atrial fibrillation, which does not apply in this case. Verapamil can produce hypotension and myocardial depression as side effects, so caution is advised.Answer C: Imaging studies are not the best initial management in a hemodynamically unstable patient.Answer E: Unsynchronized cardioversion is not the preferred approach for atrial fibrillation or other atrial and supraventricular tachycardias. Only if the defibrillator fails to synchronize in an unstable patient should this option be used in these conditions. Unsynchronized cardioversion is used when there is no coordinated cardiac electrical activity, such as in ventricular tachycardia and ventricular fibrillation.Bottom Line: For the patient with unstable tachycardia due to a tachyarrhythmia, immediate synchronized cardioversion is recommended. Drugs are not used to manage unstable tachycardia. The appropriate voltage for cardioverting unstable atrial fibrillation is 120-200 J.

The greater wing of the sphenoid is superior on the left with the occiput superior on the right A. Compression B. Flexion/Extension C. Lateral strain D. Torsion E. Vertical strain

D. Torsion Torsion occurs when the sphenoid rotates about an anterior-posterior axis relative to the occiput at the SBS. The torsion is named by the side of the more superior greater wing of the sphenoid. Torsion can be a physiological variant if it does not interfere with the CRI.

A 40-year-old Caucasian woman presents to her OB-GYN physician complaining of pain during sex. The pain is located at the opening of the vagina and is described as a burning sensation. Upon questioning, she states that her menstrual periods occur every 28 days and last approximately 6 days. During pelvic examination, no pain was elicited and no abnormalities or signs of infection were found. The next best step in the management of this patient would be: A. Psychiatric treatment B. Transvaginal ultrasound C. Transvaginal estrogen cream D. Water-based lubricant E. Laparoscopy

D. Water-based lubricant Lack of vaginal lubrication is a common cause of superficial vaginal pain. The pain develops when increased friction causes inflammation of the vaginal epithelium. It is commonly described as a burning or stinging sensation during insertion and/or prolonged intercourse. The suspicion is further confirmed by the fact that this patient had no pain during pelvic examination, which uses adequate artificial lubrication. Her pain will likely be relieved by the use of a water-based artificial lubricant. It is not recommended to use oil- or petroleum-based lubricants, as they can break down the latex of condoms. Other causes of superficial vaginal pain are atrophic vaginitis (secondary to a decrease in estrogen), infection (which she had no sign of), and vaginismus (contractions of the pubococcygeous muscle preventing penetration of anything, including a speculum).Answer A: Although psychiatric conditions such as anxiety, depression, or a history of abuse can cause dyspareunia, there is nothing in the question stem to indicate this.

A 67-year-old female is undergoing a laparoscopic hysterectomy and salpingo-oophorectomy because of a strong family history of endometrial cancer and postmenopausal bleeding. She has a history of hypertension, coronary artery disease, and previous cesarean sections. She does not smoke or drink alcohol but uses occasional marijuana. She has significant tissue texture changes to the lumbar paraspinal musculature and a flexed, rotated right, sidebent right L3 vertebra. During the operation, which of the following is the first step in assessing for damage to the patient's ureters? A. checking for adequate urine output B. intraoperative pyelography C. intravenous indigo carmine injection D. laparoscopic visualization of the ureters E. postoperative laboratory evaluation of creatine clearance

D. laparoscopic visualization of the ureters The first step in evaluating for ureteral damage would be direct visualization for gross causes. Whether open or laparoscopic, a complete evaluation of the urinary tract is done (including the bladder and contralateral ureters) before any other interventions are performed. If the Foley catheter or urine is in the field or lacerations/transections are appreciated, this is highly suggestive of ureteral injury and can easily be appreciated by direction visualization.

A 73-year-old male presents to the emergency department with the complaint of a right upper facial rash that erupted 2 days ago. He notes that the region involved is pruritic and painful. Examination reveals a vesicular rash secluded to the right side of the forehead and along the right side of the nose extending to the tip of the nose. Which ophthalmic exam would you consider in this particular clinical scenario? A. color sensitivity testing B. direct ophthalmoscopy of the optic disc C. fluorescein angiography of the retinal circulation D. fluorescein staining of the cornea E. visual field examination

D. fluorescein staining of the cornea In a dermatomal distribution of a vesicular rash in an elderly or immunocompromised patient, herpes zoster virus must be included in the differential diagnosis. Involvement of the tip of the nose along with the globe is referred to as the Hutchinson sign and warrants ophthalmic evaluation via fluorescein staining of the cornea. The dermatomal distribution of acutely erupted vesicular lesions in an elderly patient prompts the differential diagnosis to include varicella-zoster virus. In this particular distribution, which involves the tip of the nose, one must be concerned about corneal involvement, known as herpes zoster ophthalmicus, involving the V1 branch of the trigeminal nerve. Therefore, the virus also might involve the cornea along with the tip of the nose. The patient may complain of ocular pain, change in vision, and photophobia. When stained with fluorescein and viewed under a cobalt blue light, pseudodendrites appear on the surface. Hutchinson sign might also be present. This is a clinical sign that refers to vesicles on the tip or side of the nose that precede the development of ophthalmic herpes zoster.

A 24-year-old female presents with fatigue, intermittent palpitations, and depressed mood. She is depressed because she did not get accepted into a prestigious dance school. She is convinced her rejection was due to being fat, and has been on a restrictive diet for the past 2 months. Physical exam reveals signs of dehydration. Osteopathic examination is significant for hypertonicity and tenderness in the paravertebral musculature from T10-L2, representing a viscerosomatic reflex. She admits to taking laxatives everyday. Which of the following electrolyte abnormalities is most likely? A. hyperkalemia and acidosis B. hyperkalemia and alkalosis C. hyperkalemia and normal blood pH D. hypokalemia and acidosis E. hypokalemia and alkalosis

D. hypokalemia and acidosis Excess laxative use will have the same electrolyte effects as chronic diarrhea, which includes low potassium (hypokalemia) and acidosis. This is due to loss of potassium and bicarbonate from the colon. Viscerosomatic reflexes are a type of somatic dysfunction caused by changes in the autonomic nervous system. They can be acute or chronic, and are considered to be a somatic representation of visceral disease. When either branch of the autonomic nervous system (sympathetic or parasympathetic) overstimulates a particular organ, a reflex reaction occurs. The soma at the same level of the organ's autonomic innervation takes on characteristics of somatic dysfunction (TART). T10-L2 is where the sympathetic viscerosomatic reflex for the middle and lower gastrointestinal system is located. Answer A: Some common associations for hyperkalemia and acidosis include renal failure, renal tubular acidosis, diabetic ketoacidosis (DKA), and injuries such as burns and rhabdomyolysis. Answer B: Hyperkalemia and alkalosis is not a common finding.Answer C: Hyperkalemia and normal blood pH may be associated with some drugs, but most of the time, hyperkalemia is associated with acidosis.Answer E: Hypokalemia and alkalosis is associated with vomiting and excess aldosterone or renin.

A 65-year-old male presents to the emergency department with a severe occipital headache and vomiting for the past 2 hours. He has a recent history of craniotomy for a brain tumor debulking 1 week prior. Computed tomography scan of the head reveals findings consistent with a cerebellar hematoma. The most appropriate next step in management is A. admit for observation B. check coagulation factors C. fresh frozen plasma D. immediate neurosurgery consultation E. mannitol and diuretics

D. immediate neurosurgery consultation The patient in the case presents with a postoperative hematoma causing increased intracranial pressure and likely obstructive hydrocephalus due to compression of the fourth ventricle. Cerebellar hematoma is a surgical emergency. Surgical decompression can be life saving and, if done early enough, complete recovery is possible. If left untreated, a cerebellar hematoma can lead to midbrain herniation through the foramen magnum. One of the first signs of herniation is respiratory depression resulting from compression of the respiratory centers in the midbrain.

A 14-year-old male presents to his pediatrician with a complaint of right-sided chest pain after being hit with a soccer ball yesterday during practice. Radiography reveals no fractures, and electrocardiogram shows normal sinus rhythm. Physical examination shows normal vital signs; however, he has tenderness to palpation in his right rib cage, and ribs 3 to 5 on the right have decreased movement during inhalation. Direct muscle energy treatment for this somatic dysfunction would A. be contraindicated due to the acuteness of his injury B. involve the patient holding his breath at end-expiratory phase while contracting pectoralis minor C. involve the patient holding his breath at end-expiratory phase while contracting serratus anterior D. involve the physician applying an inferior traction to the posterior angle of rib 3 while the patient holds his breath at full inhalation E. involve the physician applying an inferior traction to the posterior angle of rib 5 while the patient holds his breath at full inhalation

D. involve the physician applying an inferior traction to the posterior angle of rib 3 while the patient holds his breath at full inhalation The patient has an exhalation somatic dysfunction (ESD) of ribs 3 to 5 (ribs are stuck in the exhaled position). The superior rib in the group dysfunction is the key rib in exhalation somatic dysfunctions; thus, treatment should be focused on rib 3. Direct muscle energy technique to the ribs requires respiratory cooperation by having the patient inhale or exhale deeply (depending on whether it is an ESD or an inhalation somatic dysfunction) to engage the restrictive barrier. In order to treat rib 3's ESD, the physician would contact the rib angle of rib 3 posteriorly and have the patient inhale deeply while applying an inferior traction on the rib angle; as the patient holds his breath in inhalation, the patient is instructed to perform an isometric contraction engaging the pectoralis muscle, which pulls that anterior portion of rib 3 superiorly into the restrictive barrier.

A 34-year-old female complains of hearing loss for the past 6 months. Otoscopic exam is normal. Rinne test indicates that bone conduction is audible longer than air conduction for both ears. Her mother also suffers from hearing loss. The physician attempts the vault hold to address any membranous tension within the cranium, but there is no significant dysfunction detected. Which of the following additional findings is most likely? A. autosomal recessive inheritance B. damage to eighth cranial nerve C. her semicircular canals contain dislodged otoconia D. loss of stapedial reflex E. symptoms of ear fullness and tinnitus21.0% of Users Answered

D. loss of stapedial reflex A young female with bilateral conductive hearing loss and a positive family history most likely has otosclerosis. In this disease, there is an overgrowth of the middle ear bones, most commonly the stapes, which interferes with sound conduction. When the stapes is involved, it becomes fixed to the oval window and can no longer be pulled away by the stapedius muscle in response to loud sounds. This results in loss of the stapedial reflex. Otosclerosis can also occur as a result of untreated ear infections, which leads to scarring of the tympanic membrane. When scarred, the tympanic membrane loses its ability to vibrate and distribute sound waves to the ossicles in the middle ear.The vault hold is a craniosacral treatment used to address strains at the sphenobasilar synchondrosis. The physician can use either a direct or indirect method of treatment. Most commonly, an indirect method is used to balance membranous tension. Finger placement for the vault hold is as follows: Index finger: greater wing of the sphenoid Middle finger: temporal bone anterior to the ear Ring finger: mastoid region of the temporal bone Little finger: squamous portion of the occiput

A mother complains that her 6-year-old daughter has behavior problems. Teachers say that she disrupts the class by excessive talking, interrupting other children, not raising her hand, and not staying in her seat. She does not follow instructions. The mother states that she will not invite people to the home because she is embarrassed by her daughter's wild behavior. Which of the following is commonly associated with the most likely diagnosis? A. autism B. chromosomal abnormalities C. low IQ D. oppositional defiant disorder E. Rett syndrome

D. oppositional defiant disorder The most likely diagnosis is attention deficit/hyperactivity disorder (ADHD). These children have trouble paying attention, are easily distracted, and have difficulty following instructions. Oppositional defiant disorder (ODD) is a common comorbidity. Children with ODD display hostile behavior toward authority figures. The other choices are not commonly associated with ADHD. Other comorbidities include conduct disorder, depression, and Tourette syndrome.

A 22-year-old primigravida at 31 weeks' gestation presents to the obstetric clinic for a routine prenatal examination. Her past medical history is unremarkable. The patient states she has been having leg swelling recently. A thorough review of systems is obtained, and she denies epigastric pain, headaches, or visual changes. Osteopathic examination is significant for bilateral lower extremity edema and impaired lymphatic return. Physical examination reveals a temperature of 37.4°C (99.4ºF), blood pressure of 147/95 mmHg, respiratory rate of 17/min, and pulse of 80/min. At her last visit, her blood pressure was 145/85 mmHg. The urine dipstick from today reveals 2+ proteinuria. What is the most likely diagnosis? A. chronic hypertension B. eclampsia C. gestational hypertension D. preeclampsia E. preeclampsia with severe features

D. preeclampsia Preeclampsia is diagnosed with new-onset hypertension occurring after 20 weeks' gestation with proteinuria. The combination of hypertension and proteinuria during pregnancy is diagnostic for preeclampsia until proven otherwise. Diagnostic criteria: Hypertension: Systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg on 2 occasions at least 4 hours apart after 20 weeks of gestation in a previously normotensive patient, or If systolic blood pressure is ≥160 mmHg or diastolic blood pressure is ≥110 mmHg, confirmation within minutes is sufficient Proteinuria ≥0.3 g in a 24-hour urine specimen or protein (mg/dL)/creatinine (mg/dL) ratio ≥0.3 or dipstick 1+ if a quantitative measurement is unavailable In patients with new-onset hypertension without proteinuria, the new onset of any of the following is diagnostic of preeclampsia: Platelet count 1.1 mg/dL or doubling of serum creatinine in the absence of other renal disease Liver transaminases at least twice the normal concentrations Pulmonary edema Cerebral or visual symptoms Preeclampsia usually occurs in the third trimester. If preeclampsia occurs before the third trimester, you should think of gestational trophoblastic disease. Preexisting hypertension increases the risk for intrauterine growth retardation and preeclampsia. Risk factors for preeclampsia include chronic renal disease, chronic hypertension, family history, multiple gestations, nulliparity, a very young woman with her first child, diabetes, and being African American. If the neonate is at term, definitive treatment is delivery. If the neonate is at preterm, the hypertension can be treated with hydralazine, methyldopa, or labetalol. Then, bedrest and observing the patient are advised.

A 15-year-old high school football player with no past medical history presents to the emergency room with his parents. He twisted his knee while playing earlier in the evening. He was able to stand up and walk off of the field, but was complaining of pain along the medial knee joint. At the emergency room, physical examination reveals medial joint line tenderness without swelling. A clicking and popping sound is appreciated during passive flexion and extension of the right knee and the patient finds it to be extremely uncomfortable. The patient is able to bear weight and notes only mild discomfort. He has no bony tenderness on exam. The best initial management of this patient is: A. angiography B. cortisone injection C. emergent magnetic resonance imaging of the knee D. rest and NSAIDs E. surgical consult

D. rest and NSAIDs This patient is most likely suffering from a meniscal injury, which is associated with planting and twisting of the knee. Classic findings are joint line tenderness and a popping sound with passive knee flexion and extension. Acute injuries are best treated with NSAIDs and rest. While younger patients are more likely to heal a meniscus tear, many small tears will heal with conservative management. If symptoms persist after conservative treatment, then an MRI may be indicated to better evaluate the tear. If needed, these can be repaired surgically. Common tests to evaluate for meniscal injuries include the McMurray, Apley compression, and bounce home tests, which are generally designed to elicit catching or popping of the meniscus in the setting of a tear. These tests are best appreciated by watching a video, and are often difficult to describe, but the names and procedures may be part of the COMLEX examination and should be familiar to you.

An 85 year-old-man presents to your office complaining of a tremor that has been there for at least the past year. The information is presented to you by the medical student who cannot remember the other symptoms that the patient mentioned. You can see in the chart however that he does drink daily, but does not smoke. He has a past medical history of high blood pressure that is controlled with hydrochlorothiazide. You learn the patient's additional symptoms and correctly diagnose him. You show the medical student the exhibit for teaching purposes. A is a normal cross-section of the midbrain and B is what you would expect to see in your patient. What type of tremor would you expect to find in this patient? A. cerebellar tremor B. dystonic tremor C. essential tremor D. resting tremor E. rubral tremor

D. resting tremor The tissue cross-section in image B shown depicts Parkinson disease (PD), which can be diagnosed on autopsy based on the finding of degeneration of the substantia nigra and loss of the dark pigmentation of this region. There are no physiologic, radiologic, or blood tests for confirming the clinical diagnosis of PD. The gold standard for diagnosis (without pathology) according to criteria from the Movement Disorder Society (MDS) is an expert clinician. This is a progressive disorder caused by degenerative loss of dopaminergic neurons in the brain. PD is characterized clinically by asymmetric parkinsonism and a clear and dramatic benefit from dopaminergic therapy.In order to diagnose PD, bradykinesia plus either resting tremor or rigidity must be present. Other clinical features that are supportive of the diagnosis are unilateral onset, presence of a resting tremor, and a persistent asymmetry throughout the course of the disease. A resting tremor is a 4 to 6 Hz tremor that is observed in a fully resting limb and is suppressed when initiating movement. Postural instability is also a feature of PD but usually does not appear until later in the course of the disease. Additionally, a beneficial response to dopaminergic therapy can support the diagnosis. A cerebellar tremor is a slow, broad tremor of the extremities occurring at the end of a purposeful movement. It is caused by lesions in or damage to the cerebellum resulting from a stroke, tumor, or degenerative disease, such as multiple sclerosis. Answer B: A dystonic tremor occurs in individuals with dystonia, a disorder of involuntary muscle contraction. A dystonic tremor can occur in any muscle of the body and is typically irregular. It is relieved by rest. Answer C: An essential tremor occurs with purposeful movements and can be treated with beta blockers, such as propanolol. Some patients will self treat an essential tremor with alcohol. The etiology is not known. It is the most common tremor. Children of an affected parent have a greater than 50% chance of inheriting the trait. Answer E: A rubral tremor is a coarse, slow tremor that is present at rest, at posture, and with intention. It is named for the red nucleus of the midbrain, where it is believed to originate.

DeQuervain tenosynovitis is suggested by a positive Finkelstein's test.

Finkelstein's test. With the patient's thumb inside her fist and ulnar deviation, pain is elicited over the first compartment, suggesting DeQuervain tenosynovitis, which is an inflammation of the tendons in the first compartment. It is often associated with repetitive stress activities such as a parent repetitively picking up a newborn child. Treatment initially consists of splinting, activity modification, oral steroids, or corticosteroid injections. Refractory cases many be treated with surgical release of the first compartment. Chronic stress and strain to the abductor pollicis longus and extensor pollicis brevis tendons cause the chronic inflammatory changes and symptoms associated with DeQuervain tenosynovitis.

An 8-month-old African male refugee is seen in a pediatric clinic for the first well-child visit of his life. He is exclusively breastfed, and his mother states that he has recently become less active and is not crawling as usual. His mother also notes areas of his head that seem soft. He has progressive lateral bowing of the femur and tibia. What is the most consistent diagnosis considering the above findings? A. beriberi B. kwashiorkor C. marasmus D. rickets E. scurvy

D. rickets Rickets is a disorder arising from the inadequate intake or synthesis of vitamin D. It is a bone disorder that results in incomplete ossification. This case represents a classic presentation, which is a dark-skinned child who is breastfed and not likely supplemented with vitamin D. Human milk contains only 20 to 40 IU/L of vitamin D, whereas the recommended daily supplement for exclusively breastfed infants varies from country to country and is anywhere from 200 to 600 IU/d. In the United States, the American Academy of Pediatricians recommends that exclusively breastfed babies receive 400 IU/d.Some clinical manifestations of rickets include:Delayed closure of the fontanellesParietal and frontal bossing Craniotabes (soft skull bones)Enlargement of the costochondral junction visible as beading along the anterolateral aspects of the chest (the "rachitic rosary")Formation of Harrison sulcus (or groove) at the lower margin of the thorax caused by the muscular pull of the diaphragmatic attachments to the lower ribsWidening of the wrist and bowing of the distal radius and ulnaProgressive lateral bowing of the femur and tibiaGiven that this clinical scenario describes an African child who is not receiving vitamin D supplementation and has craniotabes as well as progressive lateral bowing of the femur and tibia, the correct answer is rickets.

On physical examination, there are symmetric deformities in both hands, including ulnar deviation at the metacarpophalangeal (MCP) joints of several fingers. The left ring finger distal interphalangeal (DIP) and MCP joints are noted to be hyperextended, and the proximal interphalangeal (PIP) joint is hyperflexed. What anatomic structure injury is causing this deformity of the fingers? A. nodularity within the flexor digitorum superficialis tendon B. palmar fascia thickening C. PIP volar plate laxity D. rupture of the central slip of the extensor tendon over the PIP joint E. rupture of the flexor digitorum profundus tendon over the DIP joint

D. rupture of the central slip of the extensor tendon over the PIP joint

A 10-year-old male is brought to the trauma bay by ambulance after being involved in a car accident. The patient is accompanied by his parents. They report that he was wearing a seatbelt; however, it was not positioned correctly due to his size. He is moaning and complaining of severe abdominal pain. Vitals: HR 134/minRR 28/minTemp 36.7°C (98.1°F)BP 88/58 mmHgA CT scan shows a splenic laceration with active hemorrhage and a large amount of blood within the retroperitoneum. There is concern that he will need immediate surgical intervention with blood product support. The patient's parents state they are Jehovah's Witnesses and refuse all blood products for their child despite the admonishment of both the emergency department physician and the trauma surgeon on call. Which of the following is the correct course of action? A. contact the hospital ethics committee and wait for advice B. give the patient crystalloid and reevaluate the patient's blood pressure C. honor the parents' wishes and hold all transfusions D. transfuse as medically indicated E. try to convince the parents to consent for transfusion

D. transfuse as medically indicated principle of beneficence may require you to act on the patient's behalf when his or her life is at stake. Consent should only be presumed in emergency situations when the patient is unable to provide consent, no surrogate decision maker is available, and the emergency interventions are necessary to prevent death or disability. While the principle of respect for person obligates you to do your best to include the patient in health care decisions, the principle of beneficence may require you to act on the patient's behalf when his or her life is at stake.In the above case, consent for treatment should be sought from the parents. However, the parents are not allowed to deny life-saving emergency care to a child based on their religious beliefs. Case law has established precedent in this field. The surgeon should transfuse the child as needed and proceed with all life-saving treatments. Trying to convince the parents otherwise may appear to be the correct choice, but wasting time doing so when a patient is critically ill and requires blood products is inappropriate. In addition, exceptions to full informed consent are as follows:- If the patient does not have decision-making capacity; in which case, a surrogate decision maker must be found- A lack of decision-making capacity with inadequate time to find an appropriate proxy, such as in a life-threatening emergency; in this case, decisions are made in the patient's best interest- When the patient has waived consent- When a competent patient designates a trusted loved one to make treatment decisions on his or her behalf

A 33-year-old female comes to your office complaining of generalized fatigue that has been getting progressively worse over the past several months. She has also noticed palpitations and reports several episodes of non-bloody diarrhea during that time. You note bilateral proptosis on physical exam. Her vital signs include a blood pressure of 134/82 mmHg, a heart rate of 102/min, and a temperature of 37.1°C (98.8ºF). Which of the following best describes the pathogenesis of the patient's condition? A. cellular-mediated attack against a self antigen B. inflammation of the thyroid C. type I hypersensitivity D. type II hypersensitivity E. type III hypersensitivity

D. type II hypersensitivity This patient is presenting with signs and symptoms characteristic of Graves disease. One should always suspect this diagnosis in a patient presenting with fatigue and tachycardia with proptosis on physical examination. In this disease, antibodies against the thyroid-stimulating hormone (TSH) receptor bind and mimic the effects of TSH. Antibody binding to a membrane protein is a type II reaction. Graves disease is an example of a type II hypersensitivity reaction, where the antibodies bind to the thyroid-stimulating hormone receptor. Patients usually present with symptoms typical of thyrotoxicosis. Hyperthyroidism is characterized by both increased sympathetic and decreased vagal modulation. Tachycardia and palpitation are very common symptoms. Graves disease involves hyperplasia, not inflammation of the thyroid.--In Graves disease, the thyroid is enlarged due to hyperplasia but nontender because there is no inflammation present.

A 70-year-old diabetic male presents with nausea, bloating, and vomiting after meals for the past month. He denies trouble with swallowing. His medications include aspirin, metformin, lovastatin, and lisinopril. He occasionally takes antacids to relieve heartburn. Past medical history includes diabetic retinopathy and proteinuria. Osteopathic examination is significant for cool, fibrotic tissues with restricted range of motion overlying the celiac ganglion on the anterior abdominal wall. Which of the following will be the most helpful in his workup? A. gastric biopsy B. HbA1c C. plain film x-ray D. upper gastrointestinal series E. urea breath test

D. upper gastrointestinal series The most likely cause of the gastrointestinal (GI) distress in this patient is gastroparesis. This is a common complication of diabetes due to autonomic neuropathy. The symptoms that the patient is presenting with, as well as a history of other diabetic complications, support this diagnosis. Early satiety is another classic symptom. An upper GI series can image the esophagus, stomach, and small intestine as barium moves through. It is the initial step for the workup of gastroparesis.

A 35-year-old female presents to your clinic complaining of vulvar burning, pain, and pruritus associated with new onset dysuria. The patient was recently treated with amoxicillin/clavulanate for a tooth infection and completed the course of therapy two days ago. The patient states she is in a monogamous relationship with her husband. Which of the following findings is consistent with the patient's underlying pathology? A) Cervical Petechiae B) Clue cells C) Donovan bodies D) Painful vesicles E) vaginal ph< 4.5

E) vaginal ph< 4.5 Given the patient's recent treatment with antibiotics, vulvar pruritus, pain, and new dysuria, the most likely underlying diagnosis is vulvovaginal candidiasis. It is one of the most common causes of vulvovaginal irritation and is secondary to the overgrowth of Candida, which is generally present as normal flora in about 25% of women. It accounts for about 30% of vaginitis cases. The diagnosis can often be made on clinical grounds alone and many patients, having experienced an infection, can self-diagnose with fair accuracy. The risk factors for the development of this condition include recent antibiotic use, poorly controlled diabetes, increased levels of estrogen, and immunosuppression. Infection with Candida albicans will present with thick clumpy white cottage cheese or white curdy like discharge. Patients typically complain of burning, irritation and dyspareunia which can help differentiate this from bacterial vaginosis (BV) which generally doe not cause dysuria, dyspareunia, burning, or severe itching as BV does not cause skin changes around the vulva. KOH wet mount will reveal pseudohyphae and the pH will be 3.5 - 4.5. Treatment is typically with an antifungal including topical clotrimazole or oral fluconazole.

A 57-year-old female presents to her gynecologist with severe pruritis and dryness of her vagina since going through menopause. She has tried potent topical corticosteroids and nothing has improved her symptoms. On physical examination, the labia majora and minora appear atrophic, with smooth, white slightly raised plaques. Some plaques have coalesced and give the skin a wrinkled appearance. In addition, there are scattered excoriations. A biopsy is taken and does not reveal malignant cells. The vulva is shown in the exhibit. The most appropriate treatment is A- Ketoconazole 2% cream B-Systemic corticosteroids C-Topical corticosteroids D-Topical testosterone propionate E-Tacrolimus 0.1% ointment

E-Tacrolimus 0.1% ointment Lichen sclerosis et atrophicus (LSA) is an uncommon inflammatory disease that affects both skin and mucosal surfaces. LSA usually occurs in postmenopausal women, with a female-to-male ratio of 10:1, and is chronic in nature. Affected women complain of chronic pruritus, dysuria, and/or dyspareunia. The trigger for LSA is unknown, but trauma or radiation can induce the lesions. The lesions first appear as white patches or plaques that can coalesce to give the tissue a wrinkled, parchment paper-like appearance. In 3% of cases, it can progress to squamous cell carcinoma, hence the need for a biopsy in this scenario. The first-line treatment for LSA is potent topical corticosteroids, such as clobetasol. Since this patient has already used topical corticosteroids to no avail and squamous cell carcinoma has been ruled out, the next choice for treatment would be a calcineurin inhibitor, such as tacrolimus, which is a nonsteroidal anti-inflammatory agent. Tacrolimus is a good steroid-sparing agent and can be used long term because it does not cause skin atrophy or secondary infections, which are common with use of long-term topical corticosteroids.

A 65-year-old male is referred for prolonged, vague abdominal discomfort and feeling of fullness even after small meals. At his first visit to your office, he also complains of unintentional weight loss, intermittent nausea, and one episode of bilious emesis. The patient appears mildly cachectic and jaundiced. By exam, the patient's abdomen is soft, mildly tender in the epigastrium, with a palpable mass thought to be the gallbladder in the right upper quadrant. Osteopathic examination is significant for a posterior Chapman reflex point located at the right T7 intertransverse space. What is the most appropriate next step in management? A. Computed tomography of chest, abdomen, and pelvis B. Diagnostic endoscopic gastroduodenoscopy with endoscopic ultrasound C. Diagnostic laparoscopy with intra-operative laparoscopic ultrasound D. Exploratory laparotomy E. Computed tomography of the abdomen

E. Computed tomography of the abdomen Computed tomography should be performed if a neoplasm is suspected before more invasive measures are taken. A Chapman point represents the somatic manifestation of a visceral dysfunction. Most posterior Chapman reflex points are located between the spinous and transverse processes; they have a rubbery texture when palpated. The Chapman reflex point related to the pancreas is located at the right T7 intertransverse space. The anterior Chapman point for the pancreas is located at the right 7th intercostal space at the costal cartilage. Once a Chapman point is localized, firm pressure is applied to the point. Pressure is applied in a circular pattern with the attempt to flatten the mass, and is continued until the lesion is resolved or the patient can no longer tolerate treatment.

A 13-year-old male is brought to the emergency department after being involved in a motor vehicle accident. The boy's mother is concerned her son may bleed to death due to his history of Hemophilia A. After performing several tests, you would expect which of the following laboratory findings to be consistent with this diagnosis? A. Decreased platelet count, increased PT, increased PTT B. Decreased platelet count, increased PT, normal C. Decreased platelet count, normal PT, normal PTT D. Normal platelet count, increased PT, normal PTT E. Normal platelet count, normal PT, increased PTT

E. Normal platelet count, normal PT, increased PTT Hemophilia A is an X-linked recessive disorder that involves factor VIII of the coagulation cascade. More specifically, factor VIII is a part of the intrinsic pathway of the coagulation cascade which is measured by PTT. A deficiency in factor VIII would cause an increased PTT. Male patients with severe hemophilia present at circumcision. Easy bruising may occur at the start of ambulation or primary dentition. The patient may have a history of hemarthroses and prolonged bleeding with surgical procedures, trauma, dental extraction, and he or she may have spontaneous bleeding in soft tissues.

A 24-year-old female, G2P2, female presents to the clinic for incision check two weeks after cesarean section for breech presentation. The patient is breastfeeding with moderate tenderness. History reveals symptoms of a high fever, chills, flu-like symptoms, and breast swelling. On physical examination, the surgical incision is clean, dry, and intact without erythema. Her left breast is tender to palpation, and erythema and swelling are noted. Fluctuance is not present. Expressed milk cultures are obtained and a complete blood count is drawn. The next step in management of this patient is A. Discourage the patient from further breastfeeding B. Do nothing and have the patient follow up at her 6 week visit C. Give metoclopramide D. Incision and drainage of the breast E. Start dicloxacillin

E. Start dicloxacillin This patient is presenting with mastitis which is a cellulitis of the periglandular tissues of the breast. This infection usually occurs in breastfeeding mothers 2-4 weeks postpartum. The most common bacteria are Staph aureus. Symptoms include breast pain and redness along with high fever, chills, and flu-like symptoms. This must be distinguished from breast engorgement which presents as swollen, firm, tender breasts with low-grade fever. Another diagnosis to exclude is breast abscess which presents with erythema, point tenderness, and fluctuance. Diagnosis of mastitis includes breast milk cultures and complete blood count. Treatment of mastitis should include oral antibiotics such as dicloxacillin in addition to continuation of breastfeeding.

A 25-year-old male without known medical history presents to the emergency department after escaping from a burning building. He is brought in by paramedics, and a primary survey is performed. Physical examination reveals blistering burn injuries on his entire left upper extremity, entire right lower extremity, chest, and abdomen. His blood pressure is 120/75 mmHg and his only complaint is severe pain. He weighs 50 kg (110.2 lb). Which of the following is the most reliable patient factor to monitor in which to allow rapid and accurate adjustment of fluid administration? A) Blood pressure B) Creatinine and blood urea nitrogen C) Electrolytes D) Fractional excretion of sodium E) Urine output

E. Urine Output Routine vital signs, such as blood pressure and heart rate, can be very difficult to interpret in patients with large burns. Catecholamine release during the hours after the burn can support blood pressures despite the extensive intravascular depletion that exists.

A 75-year-old male suddenly becomes dyspneic during central line cannulation of the right internal jugular vein. Upon physical examination, breath sounds are noted bilaterally with an audible splashing murmur over the precordium. A portable chest radiograph is performed and found to be unremarkable. Vital signs include a temperature of 98.8ºF, a pulse of 121 beats/min, a respiratory rate of 19/min, and a blood pressure of 132/81 mmHg. Based on these findings, the most likely diagnosis is A. Aortic dissection B. Atrial fibrillation C. Cardiogenic shock D. Tension pneumothorax E. Venous air embolism

E. Venous air embolism Venous air embolism is a potential life-threatening complication of central line placement and typically presents with sudden-onset dyspnea with the presence of a "mill-wheel" murmur on physical examination. Venous air embolism is a potential complication of central venous cannulation and often presents as dyspnea during the procedure. Subsequent tachycardia, tachypnea, cyanosis, and altered levels of consciousness may also ensue. The presence of a loud, churning, machine-like murmur, also known as a "mill-wheel" murmur is characteristically auscultated over the precordium. Venous air embolism is one of the most feared complications of central line placement as hypotension and cardiac arrest can rapidly develop, as well as other life-threatening complications such as acute cerebral ischemia if the air is able to pass across a patent foramen ovale. To avoid venous air embolism, place the patient in the Trendelenburg position to keep venous pressure higher than atmospheric pressure. Air entering the venous circulation collects in the right heart which may cause significant strain. If the pulmonary artery pressure elevates, cardiovascular collapse may occur from significant lack of venous return to the left heart.

A 62-year-old male with a history of hypertension and diabetes presents to the emergency department after experiencing acute-onset shortness of breath and near-syncope. On examination the patient appears diaphoretic and during labored conversation becomes less responsive. Upon physical examination, the blood pressure is 82/42 mmHg with a palpable pulse. An electrocardiogram is obtained, as shown in the exhibit.What is the most appropriate next step in management? A. administer adenosine B. administer epinephrine C. administer intravenous fluids D. assess cardiac enzymes E. emergent synchronized cardioversion

E. emergent synchronized cardioversion This patient presents with near-syncope likely due to the wide-complex arrhythmia revealed on the electrocardiogram (EKG). The patient is unstable but has a pulse. The electrocardiogram shown in the image shows a regular wide-complex tachycardia. While there a few types of supraventricular arrhythmias that can cause a wide-complex tachycardia, an unknown rhythm should be presumed to be ventricular tachycardia on the test. Management of a ventricular tachyarrhythmia in an unstable patient should be focused on restoring a normal rhythm, which can be done with immediate synchronized cardioversion if the unstable patient still has a pulse. Based on the advanced cardiac life support algorithm, any unstable tachycardiac patient should undergo synchronized cardioversion beginning at 100 Joules and escalating by 100 J until a maximum of 360 Joules. This patient does not have cardiac arrest. Cardiac arrest can be caused by 4 rhythms: ventricular fibrillation (VF), pulseless ventricular tachycardia (VT), pulseless electric activity (PEA), and asystole. VF and VT are shockable rhythms whereas PEA and asystole are not. VF and pulseless VT are treated with defibrillation (unsynchronized shocks). Synchronized cardioversion is shock delivery that is timed (synchronized) with the QRS complex. This synchronization avoids delivery during the refractory period of the cardiac cycle when a shock could produce VF. Synchronized cardioversion is recommended to treat (1) unstable SVT, (2) unstable atrial fibrillation, (3) unstable atrial flutter, and (4) unstable [with a pulse] monomorphic (regular) VT. If you read the CPR/ACLS guidelines, it may be subtle but unstable monomorphic VT is not the same as pulseless VT. Unstable VT means the patient still has a pulse but they are hypotensive, altered/unresponsive, or in respiratory distress.

A 72-year-old female with Parkinson disease presents with complaints of worsening tremor. She takes labetalol, levothyroxine, and raloxifene. Physical exam reveals a pill-rolling tremor at rest and a fine tremor with hands outstretched. Her nails are separating from the nail bed, her heart rate is 128/min, and she seems anxious. Following lab confirmation, the most appropriate treatment at this time is A. hydrochlorothiazide B. iron supplementation C. levodopa/carbidopa D. levothyroxine E. to discontinue levothyroxine and administer propylthiouracil

E. to discontinue levothyroxine and administer propylthiouracil This patient is likely experiencing thyrotoxicosis caused by taking too much levothyroxine. The antithyroid compounds propylthiouracil (PTU) and methimazole (MMI) are used to block the synthesis of the thyroid hormone. Signs of thyrotoxicosis include onycholysis (Plummer nails), tachycardia, anxiety, diarrhea, and heat intolerance. Answers A & B: There are no signs of hypertension or anemia; thus, hydrochlorothiazide and iron supplementation are incorrect.Answer C: Levodopa/carbidopa would be used for Parkinson disease, but she does not seem to have worsening symptoms (cogwheel rigidity, bradykinesia, mask-like facies, stooped posture, small handwriting).Answer D: Levothyroxine is used for hypothyroidism, which can cause dry brittle nails but not likely anxiety or tachycardia.

A 46-year-old woman presents to the emergency department with severe epigastric pain that radiates to the back for the past 24 hours. She admits to a history of mid-epigastric pain, usually following a heavy meal, that resolves spontaneously. Laboratory findings show elevated direct bilirubin, lipase, and amylase. Her blood pressure is 115/70 mmHg, and heart rate is 98/min. According to the ranson criteria, the most predictive factor of a poor prognosis for this patient is: A. lipase elevated two-times more than amylase B. prolonged PT C. calcium elevated above 12-mg/dL D. AST elevated two-times more than ALT E. glucose level of 250-mg/dL

E. glucose level of 250-mg/dL This woman most likely has acute pancreatitis caused by a gallstone in the common bile duct. She has a history consistent with biliary colic which increases the risk for pancreatitis. Her elevated amylase and lipase as well as abdominal pain that radiates to the back are consistent with this diagnosis. A glucose level above 200 is one of the Ranson criteria for poor prognosis. Bottom Line: A glucose level above 200mg/dL is one of the Ranson criteria for poor prognosis in acute pancreatitis. Answer A: Elevated lipase and amylase help confirm the diagnosis but have no bearing on the prognosis. Answer B: Prolonged PT is a poor prognostic factor for chronic liver disease. Answer C: Decreased calcium (below 8mg/dL) has a poor prognosis for acute pancreatitis. Answer D: An AST elevated two-times more than ALT suggests alcoholic liver disease. A helpful mnemonic to remember causes of pancreatitis is: I GET SMASHED—I, idiopathic; G, gallstones; E, ethanol; T, trauma; S, steroids; M, malignancy, mumps (viral infections); A, autoimmune; S, scorpion stings/spider bites; H, hyperlipidemia/hypercalcemia; E, endoscopic retrograde cholangiopancreatography (ERCP); D, drugs.

Using volumetric magnetic resonance imaging, the most significant finding suggesting Alzheimer's dementia over normal aging is the presence of A. frontal lobe enlargement B. wasting of the substantia nigra C. parietal lobe enlargement D. edema of the basal nucleus of Meynert E. hippocampal asymmetry

E. hippocampal asymmetry Measures of the hippocampus and medial temporal lobe regions are useful to identify mild to moderate Alzheimer's dementia, separating them from normal elderly individuals.

A 70-year-old male is brought to his primary care physician by his wife due to memory loss, depressed mood, and frequent falls over the past 6 months. The patient admits to not feeling like himself. Upon physical examination, a hand tremor is noted that disappears when the patient points to an object. Based on this information, which of the following is the most reliable to make a diagnosis? A. computed tomography scan with contrast B. computed tomography scan without contrast C. diffusion-weighted MRI D. genetic testing E. medical history and neurological examination

E. medical history and neurological examination The most likely diagnosis is Parkinson disease (PD), which is a clinical diagnosis (medical history and neurological exam) characterized by resting tremor, bradykinesia, rigidity, and impaired posture. Depression, frequent falls, and dementia are also associated signs.

A 52-year-old male presents to your office experiencing symptoms of excessive salivation, decreased vision, and uncontrollable sweating. He is accompanied by his daughter who states that her father's personality has changed. He is found to have increased anxiety, fearfulness, insomnia, and irritability. He works in a factory making fluorescent bulbs. His vitals include temperature of 99 degrees farenheit, blood pressure of 155/90, respirations of 22, pulse of 70, oxygen saturation of 99% room air. Physical exam reveals constricted visual fields, moist skin and swollen salivary glands. Follow-up outpatient labs reveal creatinine of 1.9 mg/dL (0.6 to 1.2 mg/dL). Based on this information, what is the most likely diagnosis? A. arsenic poisoning B. carbon monoxide poisoning C. cyanide poisoning D. lead poisoning E. mercury poisoning

E. mercury poisoning This patient is presenting with the classic symptoms of mercury poisoning. Mercury poisoning can be caused by overconsumption of high-mercury-containing fish or working in occupations with exposure to artisanal mining or smelting or fluorescent bulbs. The hint provided in the stem of this question includes working with fluorescent bulbs. Symptoms include diarrhea, constricted visual fields, renal failure, tachycardia, hypertension, peripheral neuropathy, and hyperhidrosis. Hallmark of mercury poisoning is erethism mercurialis, features of which include a change in personality, anxiety, irritability, excitability, fearfulness, pathologic shyness, insomnia, memory loss, depression, fatigue, weakness, and drowsiness. Treatment with a chelating agent is indicated in patients who have a 24-hour urine concentration of 100 mcg/L or greater and who have symptoms that are attributed to mercury exposure. The agents used to treat mercury poisoning are chelating agents including dimercaprol, penicillamine, unithiol, and succimer

A 22-year-old male presents to the emergency department with a stab wound to the chest. Upon physical examination, the blood pressure is 75/50 mmHg, and the pulse is 110/min. Distended neck veins are noted; the trachea is midline. Normal breath sounds are heard on lung auscultation bilaterally. Considering the most likely diagnosis, the definitive management of this condition is A. echocardiogram B. electrocardiogram C. isotonic saline D. needle thoracostomy E. pericardiocentesis

E. pericardiocentesis Emergent pericardiocentesis is indicated for traumatic cardiac tamponade. The Beck triad includes hypotension, jugular venous distention, and muffled heart sounds. This patient is in cardiogenic shock due to cardiac tamponade from injury to the pericardium. Cardiac tamponade presents with hypotension, distended neck veins, weak heart sounds, and enlargement of the cardiac shadow on chest x-ray (due to fluid accumulation in the pericardial sac); this is also known as the Beck triad. This is a life-threatening condition that requires immediate decompression with pericardiocentesis. The onset of tamponade with pericardial effusion is directly proportional to the rate of fluid accumulation and inversely proportionally to the pericardial compliance. When compliance is high, the likelihood of tamponade is low because the pericardial space can grow to accommodate additional fluid without causing a large increase in pressure. However, when compliance is low, even very small amounts of fluid (100 to 150 mL) can cause tamponade as pericardial pressures rise and cause a drop in passive diastolic filling. Eventually, unchecked, increased pericardial volume will lead to complete circulatory collapse and death. The initial treatment for tamponade is immediate volume expansion through either blood or crystalloid products. Tamponade itself is a clinical diagnosis and does not require echocardiography, although in the modern era, bedside echocardiography is generally available to confirm the findings of tamponade and assist in drainage. If an ultrasound is not available, subxiphoid drainage can be attempted without guidance and can be a lifesaving procedure in the setting of refractory shock. The fluid can also be drained with ultrasound guidance or surgically via pericardial window.

A 30-year-old female, G3P2, presents to the high-risk obstetric clinic at 17 weeks' gestation. She admits to frequently forgetting to take her folic acid pills. Her previous child was born with a neural tube defect. The serum alpha-fetoprotein is low. The next best step in management is: A. advise her take folic acid and return in one week B. amniocentesis C. fetal non-stress test D. genetic testing E. prenatal ultrasound

E. prenatal ultrasound Bottom Line: A dating error should be ruled out before searching for a pathological cause of abnormal alpha-fetoprotein levels during pregnancy. Any abnormal alpha-fetoprotein (low or high) could be caused by a dating error; thus, this should be ruled out before searching for a pathological cause. At 17 weeks, ultrasound is the most accurate dating method. Folic acid is itself not biologically active, but its biological importance is due to tetrahydrofolate and other derivatives after its conversion to dihydrofolic acid in the liver. Vitamin B9 (folic acid and folate inclusive) is essential to numerous bodily functions. The human body needs folate to synthesize DNA, repair DNA, and methylate DNA, as well as to act as a cofactor in biological reactions involving folate. It is especially important in aiding rapid cell division and growth, such as in infancy and pregnancy. Children and adults both require folic acid to produce healthy red blood cells and prevent anemia. Folic acid supplementation during pregnancy has been shown to reduce the incidence of neural tube defects.

Which of the following signs, symptoms, labs, or radiographic findings best indicate(s) the need for surgical management in this patient? A. abdominal x-ray shows dilated loops of small bowel B. excess stool in the rectal vault C. leukocytosis and fever D. no bowel movement for 5 days E. rebound tenderness and guarding

E. rebound tenderness and guarding The video exhibit and the scenario above demonstrate the presence of peritoneal signs. The main manifestations of peritonitis are acute abdominal pain, abdominal tenderness, and abdominal guarding, which are exacerbated by moving the peritoneum (eg, coughing; forced cough may be used as a test), flexing one's hips, or eliciting the Blumberg sign (ie, rebound tenderness, meaning that pressing a hand on the abdomen elicits less pain than releasing the hand abruptly, which will aggravate the pain, as the peritoneum snaps back into place). The presence of these signs in a patient is sometimes referred to as peritonism. The localization of these manifestations depends on whether peritonitis is localized (eg, appendicitis or diverticulitis before perforation) or generalized to the whole abdomen. In either case, pain typically starts as a generalized abdominal pain (with involvement of poorly localizing innervation of the visceral peritoneal layer) and may become localized later (with the involvement of the somatically innervated parietal peritoneal layer). Peritonitis is an example of an acute abdomen and is an indication for urgent surgical intervention.

A 16-year-old female presents to the emergency department after her boyfriend broke up with her. She had been sobbing profusely according to her mother. She describes discoloration around her mouth with a tingling sensation. Physical exam reveals tachypnea, hyperpnea, and carpopedal spasm. If you were to obtain a blood gas on this patient, what acid base disorder would you expect to find? A. metabolic acidosis B. metabolic alkalosis C. nothing, the patient would have a normal arterial blood gas D. respiratory acidosis E. respiratory alkalosis

E. respiratory alkalosis This patient is suffering from hyperventilation syndrome. Tachypnea (rapid breathing) and hyperpnea (deep breathing) lead to respiratory alkalosis as CO2 is blown off, causing hypocarbia. An alkalosis is defined as an arterial pH of >7.4 and determination of a respiratory alkalosis vs. a metabolic alkalosis depends on the ABG PCO2, which will be less than 40 mmHg in a respiratory cause and greater than 40 mmHg in a metabolic cause. Other causes of respiratory alkalosis include hyperventilation (anxiety states), early aspirin ingestion, and sepsis. Treatment includes reversal of the underlying abnormality. Carpopedal spasm occurs when acute hypocarbia causes reduced ionized calcium and phosphate levels, resulting in involuntary contraction of the feet or (more commonly) the hands. As CO2 levels drop in response to tachypnea, hydrogen ions are released from their binding sites on albumin. Now albumin has a negative charge, which allows it to bind calcium, which leads to hypocalcemia. This hypocalcemia is secondary to the hypocarbia; therefore, the carpopedal spasm is not caused by primary hypocalcemia.

A 64-year-old female is brought to the emergency department after becoming unresponsive at her home. Her husband reports that she had been having persistent and progressive headaches for which she was taking an unknown medication. He states that earlier on the day of presentation she had complained of nausea and said her ears were ringing. He felt like later she became restless, was breathing quickly, and eventually became dizzy and lost consciousness. Given the information supplied, this patient is most likely suffering from toxicity due to which of the following medications? A. acetaminophen B. amitriptyline C. ibuprofen D. naproxen E. salicylates

E. salicylates Aspirin overdose and subsequent salicylate toxicity is a classic overdose with unique symptomatology and metabolic disturbances. Aspirin (acetylsalicylic acid) is available over the counter and frequently used for headaches, whether as monotherapy or in conjunction with other medicines. Additionally, it may be found in keratolytics, oil of wintergreen, Goody's powder, and bismuth subsalicylate. Upon ingestion, aspirin is converted to salicylic acid, and elevated serum levels are detectable within 4 hours.If aspirin toxicity is suspected, serum salicylate levels should be drawn as soon as possible. Symptomatology depends on time from ingestion and/or total dose ingested. Clinical signs and symptoms as well as serum concentrations guide treatment. These are summarized in the table below. Further complications and treatment will be discussed separately.

A 21-year-old male college student is brought in by his family members for evaluation. He has reportedly been living away from home in a college dorm for the past 2 years. He has no past medical history. He has recently been performing at a much lower level in school. He has stopped attending classes and upon questioning explains that the "voices told him to stay inside." Upon further questioning he explains that he is sure that the college dean has been actively surveilling his every action from hidden cameras in his dorm room. This activity has been observed for the past 3 months. What is the most likely diagnosis? A. acute psychotic disorder B. bipolar disorder C. brief psychotic disorder D. schizophrenia E. schizophreniform disorder

E. schizophreniform disorder Psychiatry questions are always about timing of symptoms. Schizophreniform disorder involves symptoms lasting 1-6 months. Symptoms of schizophrenia/psychotic disorders are characterized as negative and positive. Positive symptoms include disorganization, hallucinations, and delusions. Negative symptoms include apathy, affect flattening, and anhedonia.

A 41-year-old female presents to the family practice clinic with a facial rash that has been present on and off for several years. The woman experiences episodes of flushing and facial erythema, particularly when eating spicy foods and drinking alcohol, that precipitate a rash. She denies any other symptoms, and her only medications include lisinopril for hypertension and sertraline for depression. Which of the following is the most appropriate treatment? A. benzoyl peroxide wash B. clindamycin wash C. discontinuation of a medication D. oral metronidazole E. topical metronidazole

E. topical metronidazole Given this patient's history of rash, facial flushing, and episodic nature, she is most likely suffering from rosacea. Rosacea can often be confused with acne (even called acne rosacea if there are pustules), but there are differences, as noted below. Rosacea is a chronic inflammatory condition characterized by facial erythema and sometimes closed comedones; this is termed acne rosacea or papulopustular rosacea. Rosacea affects all ages and consists of 4 different types: erythematotelangectatic; papulopustular or acne rosacea; phymatous rosacea, which includes the presence of rhinophyma or enlargement of the nose; and ocular rosacea. Factors that commonly trigger rosacea include sunlight, emotional stress, weather changes, exercise, alcohol consumption, and spicy foods. Studies of rosacea and Demodex mites reveal that people with rosacea have an increased number of Demodex mites on the skin, with the rosacea possibly being a response of the skin to the feces of the mites. Management of rosacea involves behavioral modifications such as avoidance of triggers and strict use of daily sunscreen, in addition to topical metronidazole cream or oral antibiotics, most commonly doxycycline or tetracycline. Azaleic acid is also commonly used topically to treat the papules, pustules, and erythema associated with rosacea.

A 35-year-old female undergoes thyroid surgery. The patient is dysphonic immediately postoperatively, and is seen later during evening rounds. She appears alert and is communicating, but continues to sound hoarse and breathy. There are no signs of airway edema or trauma. Her pharynx is pink and moist. She is able to swallow without difficulty. Osteopathic examination reveals a Chapman reflex located at the C2-C7 posterior arch. The most likely diagnosis is A. bilateral recurrent laryngeal nerve injury B. hematoma C. seroma D. superior laryngeal nerve injury E. unilateral recurrent laryngeal nerve injury

E. unilateral recurrent laryngeal nerve injury Bottom Line: A patient with a hoarse voice following thyroid surgery should be immediately evaluated for recurrent laryngeal nerve injury.

A 65-year-old female is brought to the emergency department by her family for fever and confusion for the past hour. Her physical exam is significant for altered mental status. Her blood pressure is 70/40 mmHg, and her heart rate is 120/min despite administration of 1 L normal saline. A urinalysis is obtained and is positive for nitrites and leukocyte esterase with >100 WBC. Knowing her diagnosis, which of the following would be most expected? A. cool clammy extremities B. decreased cardiac output C. Grey Turner sign D. Janeway lesions E. vasodilation

E. vasodilation his elderly patient presents with septic shock presumably secondary to her urinary tract infection. Septic shock is noted to be a type of distributive shock, characterized by increased cardiac output and decreased systemic vascular resistance due to the action of bacterial toxins and endogenous immune factors. Vasodilation (aka decreased systemic vascular resistance) occurs early in septic shock and accounts for the warm extremities notable in septic individuals. This effect occurs as a result of multiple factors, including bacterial components (eg, endotoxins) as well as various cytokines involved in the immune response to infection. In addition, as blood vessels dilate, peripheral perfusion of warm blood is increased, and thus the temperature increases. As volume is diverted peripherally, relative (and often absolute) hypovolemia also contributes to the hypotension observed in septic shock.

A 55-year-old obese female presents to her primary care provider with a lesion on her right leg. Physical examination shows swelling, increased pigmentation, and an ulcer near the medial malleolus of that leg. Her blood pressure is 150/90 mm Hg and the temperature is 37.1°C (98.7°F). The most likely finding associated with her lesion is: A. cold, shiny skin over her right foot B. pain exacerbated by walking C. positive Homan sign D. reduced ankle-brachial pressure index E. venous stasis

E. venous stasis This woman most likely has a venous stasis ulcer characterized by increased pigmentation and an inflammatory reaction leading to ulceration triggered by blood pooling in the superficial veins. It can be caused by venous valve defects in superficial veins. The medial malleolus is a common location for ulceration because the superficial great saphenous vein is found there. This is in contrast to arterial insufficiency ulcers, which are most commonly found on the lateral leg. Venous ulcers are commonly seen in obese patients with long-standing varicose veins. Uncomplicated venous stasis ulcers are treated with gentle debridement and elevation of the affected limb.--Uncomplicated venous stasis ulcers are treated with gentle debridement and elevation of the affected limb.

A 67-year-old male with history of lower back pain, multilevel spinal stenosis, and prostate cancer presents to the emergency department with difficulty ambulating, right lower extremity weakness, and 10/10 lower back pain radiating into his right foot. He states that he last urinated approximately 22 hours ago and cannot initiate urination at this time. On exam, he has decreased strength in his right lower extremity with reduced sensation to pinprick. In addition, deep tendon reflexes are 0/4 in his right patellar and Achilles tendons. If presenting as a new symptom, which of the following would be a reason for an emergent neurosurgical evaluation? A. burning with urination B. diarrhea C. numbness along the inner ankle D. weakness in big toe extension E. weakness in hip flexion and ankle dorsiflexion

E. weakness in hip flexion and ankle dorsiflexion This patient is showing signs of acute cauda equina syndrome, which is compression on the lumbosacral nerve roots within the spinal canal. In this question stem, the patient has multiple risk factors including spinal stenosis and probable metastasis from his prostate cancer. This is a surgical emergency and requires immediate neurosurgical evaluation for spinal cord decompression surgery or removal of tumor. If imaging is indicated, an MRI would be the more appropriate study to choose to evaluate the cause of cauda equina syndrome.Red flag symptoms that should raise concern for cauda equina syndrome and require urgent neurosurgical evaluation include new urinary retention, urinary incontinence from bladder overflow, new fecal incontinence, saddle anesthesia, and significant motor deficits not localized to a single nerve root.Of the options listed, new weakness in both hip flexion and ankle dorsiflexion represents a motor deficit in more than 1 nerve root. Hip flexion isperformed by the iliacus and psoas muscles, which are innervated by the femoral nerve (nerve roots L2-L3). Ankle dorsiflexion is performed by the tibialis anterior, which is innervated by the peroneal nerve (nerve roots L4-L5). New motor deficits in more than 1 nerve root should raise concern for cauda equina syndrome and should prompt urgent referral to a neurosurgeon. Cauda equina symptoms such as loss of bowel and bladder continence and "saddle" anesthesia necessitate immediate neurosurgical referral.

------This is a labor act that sets minimum standards for retirement and pensions.

ERISA is the Employee Retirement Income Security Act. This is a labor act that sets minimum standards for retirement and pensions.

A 55-year-old female presents to your office with the complaint of a red irritated right eye with a persistent foreign body sensation and lacrimation. Examination reveals a wing-shaped growth extending onto the cornea. The cause of her symptoms, shown in the exhibit below, is A) Conjunctival melanoma B) Corneal ulcer C) Limbal dermoid D) Pinguecula E) Pterygium

E_ pterygium The patient presents with a pterygium. Exposure to wind, sand, and sun can lead to an elastotic degeneration of the conjunctival stroma, resulting in a wing-like growth of tissue over the cornea. Growth into the central axis of vision can impair sight. Constriction of the membrane can also lead to astigmatism, an irregular shape of the cornea leading to further refractive errors. Loss of normal conjunctival surface architecture, such as surface keratinization, and loss of goblet cells will cause symptoms of dry eye. These symptoms include excessive tearing, eye redness, and foreign body sensation. Malignant transformation of this actinic type damage is rare. Treatment includes observation and lubrication of the ocular surface in patients with mild symptoms and surgical excision in more symptomatic cases. Keen clinical observation and understanding of ocular surface anatomy in conjunction with appropriate history taking will provide the clinician with appropriate clinical management and timeliness of referral to a specialist. A pterygium is a common ocular finding in patients from subtropical areas or those with certain environmental exposures and presents as a growth over the cornea with symptoms of dry eye, irritation, redness, or change in visual acuity. Conservative therapy is the first line of treatment.

? is reserved as an alternative for those who wish to avoid hysterectomy or who are not candidates for major surgery. Ablation techniques are varied and can employ laser, rollerball, resectoscope, or thermal destructive modalities. Most of these procedures are associated with high patient satisfaction rates. Pretreat the patient with an agent, such as leuprolide acetate, medroxyprogesterone acetate, or danazol, to thin the endometrium. The ablation procedure is more conservative than hysterectomy and has a shorter recovery time. Some patients may have persistent bleeding and require repeat procedures or move on to hysterectomy. Rebleeding following ablation has raised concern about the possibility of an occult endometrial cancer developing within a pocket of active endometrium. Few reported cases exist, but further studies are needed to quantify this risk. Endometrial ablation is not a form of contraception. Some studies report up to a 5% pregnancy rate in postablation procedures.

Endometrial ablation

The answer to this type of question could nearly be answered without seeing the exhibit. Try eliminating answer choices and think about why they would even show you an image. In this case, endometriosis requires laparoscopy to confirm the diagnosis, while the other answer choices do not.

Endometriosis can cause infertility and presents with "powder burns" on laparoscopic imaging. The laparoscopic image shows the typical speckled "powder burns" of endometriosis located near the uterosacral ligament. About one-third of women with infertility have endometriosis. Although it can cause no symptoms, typical symptoms are dysmenorrhea (painful menses), dyspareunia (painful deep penetration intercourse), and dyschezia (painful defecation). If implants occur within the ovarian capsule and bleed, they form classic "chocolate cysts." A Chapman point represents the somatic manifestation of a visceral dysfunction. Most posterior Chapman reflex points are located between the spinous and transverse processes; they have a rubbery texture when palpated. The posterior Chapman reflex points related to the ovary are located at the T10 intertransverse space. The posterior Chapman reflex point related the uterus is located between the posterior superior iliac spine and spinous process of L5. Once a Chapman point is localized, firm pressure is applied to the point. Pressure is applied in a circular pattern with the attempt to flatten the mass and is continued until the lesion is resolved or the patient can no longer tolerate treatment.

Toxicology is always hit hard on COMLEX level 3 exams. Knowing antidotes to different agents is of paramount importance. COMLEX will often not give you the medication/substance that was ingested, however. You will have to derive this information based on the patient's presenting signs/symptoms. Therefore, it is important that you know what to expect in different overdose scenarios. Reviewing this information will pay dividends on test day. This patient is suffering from methanol poisoning and should be immediately treated with ethanol or fomepizole. Antidote therapy works by delaying methanol metabolism until the methanol can be eliminated from the system either naturally or via dialysis. Ethanol is believed to compete with methanol for ADH, therefore preventing the conversion of methanol to its toxic byproducts. ADH has been shown to have a 10- to 20-fold increased affinity for ethanol over methanol. By slowing methanol metabolism, ethanol is used to prevent accumulation of formic acid. Fomepizole is also metabolized by ADH but has limited use because of high cost and lack of availability.

Ethanol and fomepizole are both antidotes for methanol toxicity and are thought to compete with methanol for ADH, which prevents methanol metabolism. --Naloxone is used for the treatment of opioid toxicity. It acts as an antagonist at opioid receptors. --N-acetylcysteine regenerates glutathione and is used to prevent the toxic metabolism of acetaminophen --Methylene blue is the antidote for methemoglobinemia that should be watched for in a patient thought to have overdosed on nitrates, nitroprusside, or antimalarials. --Glucagon is used as an antidote for beta-blocker toxicity.

Bottom Line: Evisceration is the removal of all contents of the globe, however the outermost layer - the sclera - is left in tact. Think of it as removing the "viscera" or the "organs" from within the eye. A commonly chosen wrong answer is "enucleation". Enucleation involves removing the entire eyeball, with all three surrounding layers and it is most commonly indicated in the presence of malignancy. All the appendages are left intact. Enucleation makes room for a prosthesis. In Exenteration- all orbital contents (globe and surrounding structures) are removed.

Evisceration of the eye refers to the removal of the contents of the globe while leaving the sclera and extraocular muscles intact. Endophthalmitis is characterized by inflammation of the intraocular cavities (i.e. the aqueous or vitreous humor) and is most commonly caused by infection. Endophthalmitis is typically referred to as either endogenous (i.e. metastatic) or exogenous depending on the cause and source of infection. Endogenous endophthalmitis results from the hematogenous spread of organisms from a distant source of infection (e.g. endocarditis), where exogenous endophthalmitis results from direct inoculation following a penetrating eye injury, foreign bodies, or as a complication of ocular surgery. History of ocular surgery, ocular trauma, hammering steel with steel, working with wire, or working in an industrial setting is often elicited. If antibiotic therapy fails to resolve symptoms, surgery may be warranted. Evisceration refers to the removal of the contents of the globe while leaving the sclera and extraocular muscles intact. It is most commonly indicated in cases of endophthalmitis unresponsive to antibiotics and for improvement of cosmesis patients who suffer from eye blindness.

---- is the soluble storage form of iron. A patient with iron deficiency anemia would have a low serum ferritin.

Ferritin Additional laboratory values can help distinguish between the causes of microcytic anemia. Transferrin, ferritin, and percent saturation can be used to further evaluate. Ferritin is a soluble storage form of iron and is low in iron deficiency anemia. Transferrin is a transporter of iron and increases when iron stores are low. Percent saturation is the measure of iron bound to transferrin, and the percent saturation is low in iron deficiency anemia.

---------- is the leading cause of intellectual disability in the United States and has many additional sequelae, including growth impairment, very specific craniofacial abnormalities (smooth philtrum, small palpebral fissures), and central nervous system disorders. The findings, in this case, are not consistent with fetal alcohol syndrome.

Fetal alcohol syndrome

Fiberoptic bronchoscopy is the preferred method to evaluate centrally located lung lesions, whereas CT-guided biopsy remains the preferred method for the evaluation of ---------

Fiberoptic bronchoscopy is the preferred method to evaluate centrally located lung lesions, whereas CT-guided biopsy remains the preferred method for the evaluation of peripheral lesions.

------- is a complex disorder that is typically characterized by pain in both the right and left sides of the body, above and below the waist. The pain is typically constant and present for over three months. Diagnostic requirements include pain for over 3 months, no alternative diagnosis for pain, and a wide-spread pain index score of 7 or higher.

Fibromyalgia

Bottom Line: ----- presents with self-limiting febrile episodes, lymphangitis, pulmonary eosinophilia, painful lymphadenopathy, and subsequently lymphedema. The best initial diagnostic step to perform ia a blood smear.

Filariasis A blood smear should be performed in all individuals afflicted with filariasis, as it is a sensitive and cost-effective measure. Treatment of filariasis includes diethylcarbamazine, albendazole, and/or ivermectin, in conjunction with doxycycline.

de Quervain disease presents with pain near the anatomical snuffbox and a positive ------- test. Conservative treatment is the mainstay; however, surgery may be used in refractory cases.

Finkelstein test. It is a common overuse syndrome seen in construction workers and waitresses and has been associated with rheumatoid arthritis A positive test is extreme pain over the radial styloid. Conservative treatments are the mainstay and are successful in many patients. de Quervain disease that is resistant to conservative treatment may be treated with surgery. surgery will be surgical release of the first dorsal compartment

The patient undergoes drainage of his abscess. Several weeks later, he develops recurrent foul smelling drainage and stool from his wound. What is the most likely diagnosis? Fistulas are a complication of anal abscess and can occur between 30-60% of the time. The management is primarily surgical.

Fistula in ano, anal-rectal fistula The patient undergoes drainage of his abscess. Several weeks later, he develops recurrent foul smelling .drainage and stool from his wound. What is the most likely diagnosis? You may list 1 response. You answered this question correctly. Regrade. A fistula is a connection between two parts of the body (sometimes two tubular structures but also can be a tubular structure and the skin) which are not meant to be connected. When infection of the anal crypts progresses, sometimes entrance to the rectum can be obstructed, preventing the passage of purulent material into the open lumen and shunting the infection towards the surface of the skin. This results in a fistula between the rectum and the skin and is a complication of anal abscesses in between 30-60% of cases. These will often heal with surgical intervention. Fistula tracts can also be caused by inflammatory bowel disease with or without associated abscess formation due to underlying inflammation and is generally a hallmark of Crohn's disease, which can form fistulas between the colon/rectum and almost any adjacent structure: bladder, vagina, uterus, or skin.The length and direction of a fistula can be determined by following the external tract to it's other opening within the body or by the contents that are being discharged. If stool is percolating from the skin, then the fistula is likely connected to the bowel. The same goes for air within the urinary tract. Sometimes this may require the use of a colonoscope or other advanced imaging techniques such as a CT fistulogram if there is concern for fistulas between internal organs and need for delineation of the underlying fistulous anatomy. An anal fistula can often be visualized with an anoscope and a probe or if necessary a probe and a sigmoidoscope. Management is often challenging and some go on to become chronic, but treatment of the underlying disorder can often be curative. If infection is the cause, sometimes long courses of antibiotics with surgical fistulotomy are necessary. If the underlying cause is IBD, then TNF alpha inhibitors with surgical managment can sometimes resolve an initial fistula and prevent formation of future tracts.

Hammer toes are seen in ----

Friedrich ataxia.

-----presents with thin, white, fishy, musky, ivory odor. Saline wet mount shows clue cells, which are epithelial cells with multiple attached bacteria. KOH wet mount will reveal a fishy odor which is evidenced by a positive whiff test. Vaginal pH > 4.5. Treatment is metronidazole. As stated above, ?does not generally cause skin changes and would not present with dyspareunia, pruritis, burning, or dysuria.

Gardnerella vaginalis bacterial vaginosis

Bottom Line: Gastroschisis is a congenital abnormality involving the GI tract characterized by the evisceration of intestine through the lateral abdominal wall.COMBANK Insight : Congenital malformations of the GI tract are a COMLEX favorite and routinely appear in some format in the Pediatric portion of the exam. This topic is routinely tested in a matching format similar to what is shown above. Make sure you are able to distinguish between these based on presentations alone.

Gastroschisis is a congenital abnormality involving the gastrointestinal tract characterized by the evisceration of intestine through the abdominal wall, just lateral to the umbilicus. Unlike an omphalocele, the mass is edematous, dark in color, and typically appears to be covered by a gelatinous matrix of greenish material. There is no involvement of the umbilical cord. Treatment is coverage of the abdominal contents with primary staged closure. An omphalocele is a type of abdominal wall defect that occurs when the abdominal viscera herniates through the umbilicus into a sac covered by peritoneal tissue and amniotic membrane. Diagnosis is most commonly made by prenatal ultrasound although diagnosis can also be achieved through AFP screening. Polyhydramnios is often noted in utero. Also of importance is that one in ten patients diagnosed with omphalocele with also have Beckwith-Wiedemann syndrome, a condition characterized by exophthalmos, macroglossia, gigantism, hyperinsulinemia and hypoglycemia. Don't confuse the diagnosis of omphalocele with gastroschisis, a similar birth defect, but one that does not involve the umbilical cord, and is not enclosed in a membranous sac.

--caused by Klebsiella granulomatis and usually presents as nodular lesions which can develop into painless ulcers. The edges of these ulcers can slowly enlarge, are friable, and have rolled margins. Giemsa stain reveals donovan bodies. A biopsy is required for accurate diagnosis.

Granuloma inguinale

A 45-year-old female complains of heat intolerance and weight loss. Her spouse notes her to be more anxious and states that her eyes are "bulging out of her head" which has worsened over several months. On evaluation by her PCP, she is noted to have an elevated free T4 and low TSH. On exam, her thyroid is smooth and grossly enlarged. What is the most likely diagnosis?

Graves Disease The most likely diagnosis in this question is Graves' Disease due to hyperthyroidism with a high T4 and suppressed TSH, a smooth, enlarged thyroid gland making multinodular goiter less likely, and the specific finding of Graves' ophthalmopathy. Graves disease is the most common cause of hyperthyroidism and generally presents with signs and symptoms of thyrotoxicosis. In addition, there can be a visible or palpable goiter, which may have an audible bruit due to increased vascularity of the thyroid tissue. Tracheal compression can cause symptoms of airway obstruction and if severe enough, cause esophageal compression leading to dysphagia, through compromise of the airway requiring emergency intervention is relatively rare.

The child in this scenario has acute otitis media (AOM), which can be determined from the physical examination findings of a red, bulging, and nonmobile tympanic membrane. AOM is most commonly caused by Streptococcus pneumoniae or Haemophilus influenzae (nontypeable strain). Because S pneumoniae is not listed in the above choices, the correct answer is H influenzae. While there is a vaccine for most strains of Haemophilus influenzae, it does not cover the nontypeable strain. First line treatment is Amoxicillin followed by Augmentin. Treat children < 2 years for 10 days and those ≥2 years for 5 to 7 days. Those allergic to penicillin can use azithromycin or clindamycin.

Haemophilus influenzae generally does not progress to mastoiditis, but may be associated with more complex otitis media, including increased risk for treatment failure, recurrence despite appropriate antibiotic therapy. Antibiotic treatment must be initiated early in the treatment of otitis media.

Molluscum contagiosum is a poxvirus infection that causes self-limiting flesh-colored, slightly umbilicated, dome-shaped papules. Diagnosis is usually clinical, however, characteristic ------- can be observed upon histological examination.

Henderson-Paterson inclusion bodies Henderson-Paterson bodies are intracytoplasmic inclusion bodies observed with a molluscum contagiosum infection. Molluscum contagiosum is caused by a poxvirus that infects epithelial cells and disrupts the bonds that normally hold them together. The skin lesions are slightly umbilicated, dome-shaped, flesh-colored papules and the patients are otherwise usually asymptomatic. Scratching or touching the papules can cause autoinoculation to another body part. It can be transmitted by direct skin contact (e.g. children sharing a bath, daycare centers, or gymnasiums). In adults, it is considered a sexually transmitted disease and papules usually occur in the genital region. Adults with widespread lesions should raise suspicion for HIV or immunosuppression. In such cases, treatment of the HIV and increased CD4 counts should lead to the resolution of the lesions. Lesions appearing in the genitals of a young child must raise suspicion for sexual abuse. Diagnosis is usually solely by clinical exam, but if lesions are atypical, removal of a small lesion with a curette and histological examination can confirm. Infected cells will appear dark and round and disperse easily with pressure, unlike normal epithelial cells which remain stuck together. Lesions are typically self-limiting, but can last up to nine months. Other treatment options include cryotherapy, topical cantharidin or retinoids, curettage, or laser removal. Treatment for molluscum contagiosum in children is commonly observation because the disease is self-limiting. There are a variety of other treatment options. Cryosurgery can be used but is often limited to adults or older children because it is quite painful. In addition, curettage and cantharidin are other treatment options that can be used on children.

For extrapulmonary sarcoidosis involving such critical organs as the heart, liver, eyes, kidneys, or central nervous system, corticosteroid therapy is indicated.

High-resolution CT scanning of the chest may be helpful. It identifies active alveolitis versus fibrosis. It correlates with yield of biopsy. A diagnosis of exclusion, sarcoidosis is more common in African-American patients and is characterized by non-caseating granulomas. Patients present with bilateral hilar lymphadenopathy and pulmonary infiltrates on chest radiograph. Angiotensin-converting enzyme (ACE) levels may be elevated, secondary to being secreted from non-caseating granulomas and is sometimes useful in the workup of sarcoidosis. Sarcoidosis is a multisystem inflammatory disease of unknown etiology that predominantly affects the lungs and intrathoracic lymph nodes, characterized pathologically by non-caseating granulomas. Presentation depends on the extent and severity of the organ involved. Angiotensin-converting enzyme (ACE) levels may be elevated, secondary to being secreted from non-caseating granulomas. Furthermore, these granulomas also secrete 1,25 vitamin D, which results in hypercalcemia and hypercalciuria.

A 23-year-old female presents complaining of a 2-day history of a rash involving both lower extremities. She also reports some gingival bleeding that she first noticed a couple of days ago. She states she just got over "the flu," but is feeling better. Her past medical history is unremarkable, and she takes no medications. Vital signs are normal. Physical examination shows small nonpalpable punctate purple lesions involving the bilateral lower extremities. CBC and coagulation studies show the following: Fibrinogen and fibrinogen degradation products are both within normal limits. only noted decrease was in platelets Which of the following is the most likely diagnosis? A. aplastic anemia B. disseminated intravascular coagulation C. immune thrombocytopenic purpura D. thrombotic thrombocytopenic purpura E. von Willebrand disease

Immune thrombocytopenic purpura presents as isolated thrombocytopenia and is common after viral illness. Immune thrombocytopenic purpura (ITP) is characterized by isolated thrombocytopenia. The name has changed from "idiopathic" to "immune" thrombocytopenic purpura. Acute ITP often follows an acute infection and has a spontaneous resolution within 2 months. Chronic ITP persists longer than 6 months without a specific cause. Clinical presentation usually includes purpura or petechiae, mucosal bleeding, and menorrhagia/metrorrhagia in females. Coagulation studies are normal except for thrombocytopenia. It is believed to be an autoimmune disorder in which IgG antibodies bind to platelets and lead to their excessive destruction in the spleen. --Fibrinogen and fibrinogen degradation products (FDPs) are both normal in this patient; therefore, disseminated intravascular coagulation, which is associated with low fibrinogen level and increased FDP levels, is not the correct answer. ---Thrombotic thrombocytopenic purpura, which can also present with thrombocytopenia and petechial bleeding in the lower extremities, is less likely since the patient does not have neurologic symptoms, renal failure, or symptoms of hemolytic anemia characteristic of this syndrome. ---Coagulation studies are normal; therefore, von Willebrand disease is not a correct option.

---- is considered a first-line medication in patients with an HbA1c >10.0%. Some of these patients may have unrecognized type 1 diabetes and others will have type 2 diabetes with severe insulin deficiency. Insulin can be titrated rapidly to better get the glucose levels under control.

Insulin

L------ is a symptom of congestive heart failure seen in the dilated cardiomyopathy of chronic Chagas disease. This resident has been bitten by the reduviid bug (kissing bug), the vector for Trypanosoma cruzi. T. cruzi is a blood-borne flagellate protozoa found in Texas, Mexico, Central and South America. Patients who forget their insect repellent and bed nets run the risk of being "kissed" by this bug. While the bug feeds on humans it defecates trypomastigotes onto the victim where they subsequently tunnel into the host. From here, they becomes amastigotes, multiply and invade local skin, macrophages, lymph nodes, and distant organs via hematogenous spread.Acute Chagas disease is characterized by a chagoma at the site of entry, along with constitutional symptoms; there can also be EKG changes and sometimes meningoencephalitis. The acute illness lasts approximately 1 month, and then patients enter the intermediate phase where there are no symptoms, but low levels of parasites in the blood and antibodies against the parasite. Many stay in this stage for life, but some (for unknown reasons) advance to chronic Chagas disease where the heart, colon, and esophagus are classically affected. Patients experience heart block, ventricular tachycardia, dilated cardiomyopathy, megaesophagus, and megacolon.

Lower extremity edema The reduviid bug (kissing bug) is the vector for Trypanosoma cruzi, the cause of Chagas disease. Acute Chagas disease is characterized by chagoma, constitutional symptoms, and possibly cardiac and neurologic manifestations. Chronic Chagas disease causes dilated cardiomyopathy, megaesophagus, and megacolon.

Bottom Line: MRI is the imaging technology of choice in cases of suspected placenta accreta, increta, and percreta.

Magnetic resonance imaging (MRI) is the gold standard in evaluation of placenta accreta. MRI can aid in the diagnosis by establishing the level and amount of invasion of the placenta. This can decipher whether the placenta invades into the myometrium, the serosa or even beyond the uterus into nearby structures or organs, such as the bladder. Also important in the workup of placenta accreta is a urinalysis. Hematuria can be a sign of placental invasion into the bladder. Further, serum alpha-fetoprotein (AFP) is generally elevated in cases of abnormal placental implantation. An AFP should be ordered to evaluate for abnormal placentation.

----- predisposes newborns to persistent pulmonary hypertension and occurs following inspiration of meconium-stained amniotic fluid. It is more likely seen in most term infants. There is generally meconium-stained fluid on the infant. On x-ray the infants lungs generally appear hyperinflated with linear densities.

Meconium aspiration syndrome

The treatment of choice for Conn syndrome (primary hyperaldosteronism) due to an adrenal adenoma is surgical resection.

Medical treatment of choice for idiopathic adrenal hyperplasia, which also causes primary hyperaldosteronism, is spironolactone. The confirmatory test of choice is a 24-hour urinary aldosterone test or a salt loading test. A CT of the abdomen will not show a mass as it does in Conn syndrome. Another alternate medical treatment for idiopathic adrenal hyperplasia is eplerenone, which does not have the gynecomastia side effects of spironolactone. Hyperaldosteronism can be divided into 2 types: primary hyperaldosteronism, in which the adrenal gland is producing excess aldosterone; and secondary hyperaldosteronism, in which there is too much renin causing excess secretion of aldosterone (such as in renal artery stenosis). Primary hyperaldosteronism can be caused by an adrenal adenoma, adrenocortical carcinoma, and rarely bilateral hyperplasia. The patient in this scenario has primary hyperaldosteronism, also known as Conn syndrome, which is caused by an adrenal adenoma. Patients present with hypertension, hypernatremia, hypokalemia, low renin levels, and metabolic alkalosis. Initial screening test of choice is a renin level. In primary hyperaldosteronism, there is a low renin level. In secondary hyperaldosteronism, there is high aldosterone that fails to suppress with saline load and high renin level. The next best test is a plasma aldosterone to renin ratio while the patient is supine and hydrated. A plasma ratio of >30 is diagnostic of primary disorders, and a plasma ratio <10 is diagnostic of secondary disorders. Renin levels are low in primary hyperaldosteronism. A CT of the abdomen should be ordered to look for an adrenal mass. Treatment of choice for Conn syndrome is surgical resection of the adrenal adenoma.

------accounts for 6% to 8% of thyroid cancers. They are found in the parafollicular calcitonin-producing C cells. As a result, calcitonin levels are elevated. It is important to remember that the paradoxical effect of an increase in parathyroid hormone overcomes the high levels of calcitonin and results in abnormally high levels of serum calcium. Medullary thyroid cancers are associated with multiple endocrine neoplasia (MEN) type 2 and should prompt further workup. MEN 2A is associated with pheochromocytoma and parathyroid gland hyperplasia. MEN 2B is associated with pheochromocytoma, mucosal neuromas, and marfanoid habitus.

Medullary carcinoma

---- leads to a decrease in estrogen with an increase in follicle-stimulating hormone (FSH), luteinizing hormone (LH), and gonadotropin-releasing hormone (GnRH).

Menopause Follicle-stimulating hormone (FSH) levels can be used to confirm the diagnosis of menopause. Increases in FSH out of proportion to increases in luteinizing hormone (LH) confirm the diagnosis of menopause.

-------can be caused by overconsumption of fish. It presents with diarrhea, constricted visual fields, renal failure, tachycardia, hypertension, peripheral neuropathy, and hyperhidrosis. It can be treated with chelating agents such as succimer, dimercaprol, or penicillamine.

Mercury poisoning

------ is a muscle relaxant. The most common side effect is drowsiness, and an overdose of this medication generally has specific CNS effects, including decreased level of consciousness, hypotension, and potentially seizures. It would not be expected to cause hyperthermia or changes to the EKG.

Methocarbamol

----- acts as a reducing agent. It reduces oxidized heme groups from the Fe3+ state to the Fe2+ state. It is used to treat methemoglobinemia.

Methylene blue

----- presents with proptosis, eye pain, and a normal ophthalmologic exam of the retina.

Orbital cellulitis The most likely diagnosis in this patient is orbital cellulitis. Orbital cellulitis is an emergency because improper diagnosis and treatment may lead to blindness. Patients commonly complain of pain when moving the eye, sudden loss of vision, bulging of the eye or eyes that are infected, and limited eye movement. Along with these symptoms, patients typically have redness and swelling of the eyelid, decreased extraocular movements, pain, discharge, inability to open the eye, fever, and lethargy. Orbital cellulitis is usually caused by extension of an infection of nearby structures, trauma, or previous surgery. Staphylococcus aureus, Streptococcus pneumoniae, and beta-hemolytic streptococci are 3 bacteria that can be responsible for orbital cellulitis.

A 9-year-old female presents to the Emergency Department with her mother complaining of a droopy right eye and severe pain with eye movement for 2 days. Review of systems indicates mild fever and nasal congestion. She has a past medical history of asthma and recurrent sinus infections. Physical exam reveals swollen upper lid, pain with extraocular movement and mild proptosis. Visual acuity is 20/20 in both eyes and pupils are equally reactive bilaterally with no abnormalities. On palpation of cranial motion, the physician notes caudad deviation of the sphenobasilar synchondrosis, with a resultant decrease in the amount of flexion. Indicated treatment for this condition includes: hospitalization and IV Abx

Orbital cellulitis presents with fever, eyelid edema, headache, pain with eye movement and in later stages proptosis (protruding of the eye from the orbit). The most common cause is ethmoidal or frontal sinusitis but it may also be the result of penetrating trauma. Common organisms in this age group include Staphylococcus and Streptococcus. Subperiosteal abscesses may form from extension of sinusitis. Treatment includes hospitalization for intravenous antibiotics. When the presentation is more advanced and severe, including severe proptosis, change in visual acuity or papillary abnormalities indicating optic nerve involvement, emergent surgical drainage is warranted. Orbital imaging is indicated in evaluation. Leaving orbital cellulitis untreated may result in loss of the eye as well as potential cavernous sinus thrombosis.

Heberdens nodes are found in patients with osteoarthritis. Typically an aspiration is not needed for the diagnosis. Osteoarthritis occurs more commonly in patients >40 years old, and the joints are not tender to touch or warm such as in rheumatoid arthritis and septic arthritis. Patients complain of asymmetric joint pain that is worst with use. Physical exam findings include Heberden nodes, which are osteophytes on the DIP, and Bouchard nodes, which are osteophytes on the PIP. Osteoarthritis spares MCP joints, and this can be used as a distinguishing factor from rheumatoid arthritis. Treatment is with NSAIDs or acetaminophen.

Osteoarthritis spares MCP joints, and this can be used as a distinguishing factor from rheumatoid arthritis. Treatment is with NSAIDs or acetaminophen.

pagets disease of bone patients may be otherwise asymptomatic and present only with elevated alkaline phosphatase on laboratory workup or with abnormalities found incidentally on x-ray. Symptomatic individuals can present with pain at localized areas of bone enlargement and deformity resulting from bone lysis and/or formation.

Paget disease is caused by an increase in all phases of bone remodeling and results in bony overgrowths and can also result in hearing deficits caused by compression of the vestibulocochlear nerve. Paget's disease can be treated with IV zoledronic acid, a potent bisphosphonate. Alendronate and Risedronate can also be used as oral treatment. Bisphosphonates are utilized in the management of Paget's disease of the bone. A more potent bisphosphonate has a higher likelihood of inducing remission of Paget's disease of the bone than a less potent bisphosphonate. A single intravenous dose of 5 mg of zoledronic acid can provide a 96% remission rate for six months. Although IV zoledronic acid is the most efficient, Alendronate and Risedronate can also be used as oral treatment.

Paget disease of bone is a disease of increased bone destruction by osteoclasts and bone production by osteoblasts. Etiology is largely unknown but is thought to be caused by a virus. Some element of genetic predisposition plays a role. Paget affects adults in the range of 50 to 90 years old, with males slightly more often affected than females. Patients may be asymptomatic for many years and finally present with the complaint of deep bone pain, hearing loss, increased skull size, and bone deformity. The hearing loss symptoms are caused by both compressions of cranial nerve VIII and osseous changes of the ossicles of the ear, which will result in both conductive and sensorineural hearing loss. These findings may also be found independent of each other. Symptoms correlate with the involved bones.Lab abnormalities include an elevated alkaline phosphatase and radiographic abnormalities, such as a pathologic fracture. The skull, spine, pelvis, and proximal long bones are most commonly involved, with polyostotic involvement in the majority of cases. Treatment depends on symptoms, because asymptomatic patients require no treatment.Bisphosphonates can be used to reduce bone turnover and decrease bony changes. Rarely, Paget disease can progress to Paget sarcoma, which is a malignant neoplasm, and surgical resection would be necessary. Pathologically, the deformed bone trabeculae and architecture result in bone weakening, fracture, and secondary arthrosis.There are 3 distinct stages of Paget disease: the lytic, mixed lytic and blastic, and sclerotic stages. Radiographs of patients with Paget disease classically reveal lytic areas with a thinned cortex in the early lytic stage, with a mixed lytic and sclerotic appearance with coarse trabeculae and cortical thickening in the later phase. In the radiograph shown in the exhibit, the bone window of the CT reveals a thickened calvarium with involvement of the inner and outer tables with foci of sclerosis within the skull, termed "cotton wool" spots. These findings are classic for Paget disease of the skull. An image of a CT scan with a patient with Paget disease is shown below:

Paget disease of bone has many different presentations, and the osseous findings are classic in appearance. Hearing loss occurs from both conductive and sensorineural causes. The classic appearance of Paget disease is widened trabeculae and increased bone size, typically seen in long bones. The skull findings are classic and display patchy areas of dense and lucent bone, giving it the "cotton wool" appearance.

Thyroid nodules are common and increase in incidence with age. Most are found to be benign, but proper workup must be initiated to determine etiology. After checking a thyroid-simulating hormone (TSH), an ultrasound is usually the first step in diagnosis to determine whether the nodule is cystic or solid. Next, a radioactive scan determines whether the nodule is hot or cold. Cancers are usually cold and solid. If the nodule is determined to be solid, a sample study needs to be taken. Fine-needle aspiration (FNA) can be used for nodules <3 cm. Nodules >3 cm need a biopsy for further evaluation. ----------is the most common type of thyroid carcinoma, accounting for 75% to 80% of thyroid cancers. Characteristics include Orphan Annie nuclei (empty nuclear papillae) and psammoma bodies (as described in the question stem). These tumors are typically slow growing. They are most often spread via the lymphatic system. Therefore, palpable cervical lymph nodes are a common finding.

Papillary thyroid carcinoma

------ represents a risk equivalent for coronary heart disease.

Peripheral arterial disease Claudication is a clinical manifestation of peripheral arterial disease. Peripheral arterial disease represents noncoronary atherosclerotic cardiovascular disease and is considered to confer the same risk of a coronary event as having diagnosed coronary artery disease. It is generally felt that if a patient has severe arterial disease in one vascular bed, it is likely present in another. Patients with peripheral arterial disease can have a risk of subsequent cardiovascular events similar to patients with established coronary heart disease. It is essential to recognize the risk and undertake aggressive risk factor modification in these patients with smoking cessation, glucose control, blood pressure control, and lipid managment. The other noncoronary risk equivalents include carotid artery disease and abdominal aortic aneurysm.

-------- headaches are a common complication of epidural anesthesia that occur from puncture of the dural membrane. Pain is relieved with supine posture, and the initial treatment is with analgesia, bed rest, caffeine, and fluids.

Postdural puncture headaches Epidural blood patch is the most effective treatment for patients suffering from post-dural puncture headache. Most patients have near instantaneous relief. The procedure is performed by placing an epidural catheter and injecting the patient's own venous blood into the epidural space. One theory is that this blood leads to clot formation around the previous dural leak to prevent continued CSF spread into the epidural space. Relief is usually instantaneous, although patients can describe a feeling of "fullness" where the patch was placed. Although other treatments exist for patients suffering from a PDPH, placement of an epidural blood patch remains the standard of care due to its ease of use and excellent efficacy.

Suspect Behçet syndrome in patients presenting with genital and oral ulcers in the presence of uveitis. Behçet syndrome is a multisystem disorder presenting with recurrent oral and/or genital ulcerations, chronic relapsing uveitis that may cause blindness, and neurologic impairments. The cause is unknown though it is primarily classified by auto-inflammation of the vessels. Diagnostic criteria established by the International Study Group for Behçet syndrome requires the presence of recurrent oral ulceration in the absence of other clinical explanations and two of the following: recurrent genital ulceration, eye lesions, skin lesions, and/or a positive pathergy test (pustular reaction of the skin in response to intradermal needle prick). The medication of choice for controlling acute exacerbations associated with this condition is? Reiter syndrome, also known as reactive arthritis, is a disorder that causes three seemingly unrelated symptoms: arthritis, conjunctivitis, and urethritis. Remember the saying "can't see, can't pee, and can't climb a tree." ? syndrome is a type of developmental disorder that involves difficulties with concentration, hyposensitivity/hypersensitivity to certain stimuli, sensory integration problems, self-stimulating behaviors such as rocking back and forth or verbal utterances, and difficulty interpreting facial expressions and other social cues.

Prednisone Asperger

This pregnant patient is presenting with new onset hypertension in the setting of thrombocytopenia concerning for new onset preeclampsia. It should be noted that the guidelines for the diagnosis of preeclampsia have been altered, and no longer require the presence of proteinuria. Preeclampsia should be diagnosed based on a previously normotensive woman with new onset of hypertension (systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg on at least two occasions at least four hours apart) after 20 weeks of gestation AND new onset of 1 or more of the following:- Proteinuria ≥0.3 g in a 24-hour urine specimen or protein/creatinine ratio ≥0.3 (mg/mg) in a random urine specimen or dipstick ≥2+ if a quantitative measurement is unavailable - Platelet count < 100,000/microL - Serum creatinine >1.1 mg/dL or doubling of the creatinine concentration in the absence of other renal disease- Liver transaminases at least twice the upper limit- Pulmonary edema- Cerebral or visual symptoms (eg, new-onset and persistent headaches not accounted for by alternative diagnoses and not responding to usual doses of analgesics; blurred vision, flashing lights or sparks, scotomata)

Preeclampsia presents with new onset hypertension AND either proteinuria or thrombocytopenia or doubling of creatinine or elevated liver transaminases at least twice the upper limit pulmonary edema or cerebral symptoms or visual symptoms

Bottom Line: Lifestyle modifications include a low-fat, low sodium diet and exercise, as well as cessation of alcohol or tobacco abuse (if present).COMBANK Insight : Hypertension will be a difficult topic to test on the COMLEX because of the rapidly changing guidelines. General ideas that have remained constant, such as which medications to recommend and why, such as ACE inhibitors, diuretics, and CCBs, and lifestyle modifications have remained the same and will likely be tested rather than blood pressure cutoffs. Diuretics or CCBs should be started once the patient enters stage II hypertension or if a patient in stage I hypertension has risk factors such as diabetes or cardiovascular disease.

Prehypertension was defined previously as blood pressure above normal, but below hypertension. That category was eliminated in the American Heart Association (AHA) definition that was released in the fall of 2017. The current blood pressure cutoffs are as follows:Normal: Less than 120/80 mm HgElevated: Systolic between 120-129 and diastolic less than 80Stage 1: Systolic between 130-139 or diastolic between 80-89Stage 2: Systolic at least 140 or diastolic at least 90 mm HgThis patient has Stage 1 hypertension as per the new guidelines. Requirements for the diagnosis of hypertension includes blood pressure elevated above normal on two separate occasions that are at least one week apart. Risk factors for the development of hypertension include being overweight, a family history of hypertension, smoking or alcohol use, sedentary lifestyle, and high sodium intake. Patients with elevated blood pressure and hypertension are at increased risk of developing cardiovascular complications; therefore, lifestyle modifications should be implemented, including a low-fat, low sodium diet and increased exercise.Answers A & B: Rechecks in three or six months do not address the current problem. This patient has had elevated blood pressure on two separate occasions that are more than one week apart and therefore should have some kind of intervention. Given that he has no risk factors and has never had a cardiovascular event, he should be counseled on lifestyle modification.

----- is a very common finding in newborn females. Vaginal bleeding occurs due to endometrial sloughing that takes place following the rapid decline of circulating maternal estrogens that were once present in utero. It is appropriate in this scenario to reassure the mother of the benign nature of this finding as this can be a very scary event for a new parent. Bleeding is normal and usually resolves within 10 days following birth.

Pseudomenses

----- results in the preferential publication of positive results and can result in a false positive, or type I error, in a meta-analysis.

Publication bias Publication bias refers to the higher likelihood of publishing positive results. This is a major potential source of error for meta-analyses, which strive to summarize the available knowledge in a given field. If the published data have a systematic bias toward rejecting the null hypothesis, then the result of the meta-analysis will be a higher likelihood of false-positive results. A false positive, or rejecting the null hypothesis when in fact no difference exists, is a type I error. The graphical way of evaluating publication bias is a funnel plot, which plots effect size as a measure of its precision.

Injectable progesterone in the form of a medroxyprogesterone acetate shot is a common means of birth control in the United States and has a failure rate of only 0.3%, making it a very reliable method of contraception. However, during the first year of use of Depo-Provera, over 70% of women develop irregular menstrual bleeding and may also experience weight gain, depression, alopecia, and breast tenderness, as in the case above, making medication side effect the correct answer.

Questions dealing with birth control are very common. It is important to know the side effects of different contraceptive methods, as well as the advantages/disadvantages of each. Remember, serious complications may occur in smokers over the age of 35 who take combined hormonal oral contraception. Such complications include pulmonary embolism, ischemic stroke, and deep venous thrombosis.

Options for prostate cancer treatment require evaluation of patient goals (palliation, life extension, or cure), life expectancy, and comorbidities. The spectrum of treatment ranges from active surveillance to systemic chemotherapy, androgen depletion therapy, radiation, and radical surgery including prostatectomy and orchiectomy. ------- is useful in management of pain caused by metastatic prostate cancer.

Radiation beam therapy

------is a human monoclonal antibody intended for the prophylaxis and treatment of inhaled anthrax. A common therapeutic combination is raxibacumab plus ciprofloxacin, which are given intravenously. Antibiotics are usually taken for 60 days by people who have been exposed to anthrax, because it can take spores that long to germinate. Septicemic anthrax refers to overwhelming infection by anthrax bacilli. This form of anthrax may complicate inhalational anthrax. The anthrax bacilli multiply in the blood and proliferate to outnumber red blood cells. Another name for anthrax is black blood, which refers to the very dark color of the blood of animals or humans with overwhelming septicemic anthrax. Because humans are relatively resistant to invasion by Bacillus anthracis, most cases of septicemic anthrax occur following inhalational anthrax. The number of organisms released from the liver or spleen into the bloodstream overwhelms host defenses and produces massive amounts of lethal toxin that cause shock and death.

Raxibacumab

Methanol poisoning leads to metabolic acidosis, which is manifested by a low serum bicarbonate level. Anion-gap metabolic acidosis results from elevated lactate and ketone levels, which is likely due to the accumulation of formic acid. This may necessitate the administration of bicarbonate, as well as assisted ventilation. Bicarbonate has been shown to potentially be effective in the reversal of the visual deficits associated with the ingestion of methanol. The administration of bicarbonate may also help to decrease the amount of active formic acid.

Respiratory alkalosis results from any process that causes the lungs to exhale carbon dioxide excessively. Examples include pulmonary embolism and breathing at high altitudes. Respiratory acidosis may be caused by chronic obstructive pulmonary disease (COPD), barbiturate ingestion, chronic lung disease, or other causes. It results from any process that causes the lungs to retain carbon dioxide. Anion-gap metabolic acidosis results from elevated lactate and ketone levels, which is likely due to the accumulation of formic acid. Nonanion gap metabolic acidosis has many causes. Metabolic alkalosis may be caused by diuretic use, vomiting, and excessive bicarbonate consumption.

--------- can occur in the setting of blunt trauma. Patients may describe a veil or curtain floating in one particular field of vision or a complete loss of vision if the detachment involves the central area of vision, the macula. Retinal detachments would not be seen on examination of the anterior chamber, however, an altered red reflex may be present. Bleeding in the posterior chamber, which may be concomitant with a retinal detachment, would not fill the anterior chamber.

Retinal detachment

Rheumatoid arthritis presents with Boutonniere deformity and joint fluid with WBC >2,000/μL and neutrophils between 60% and 80%.

Rheumatoid arthritis is an inflammatory disorder that affects mostly female patients, most commonly between 20 and 45 years old. Patients typically present with fever, malaise, symmetric joint involvement, prolonged morning stiffness, and swan neck (flexion of distal interphalangeal joint [DIP] and hyperextension of proximal interphalangeal joint [PIP]) and Boutonniere deformities (hyperextension of DIP and flexion of PIP). The joints most commonly affected are PIP, metacarpophalangeal (MCP), and wrists. Other physical exam findings include rheumatoid nodules, ulnar deviation, subluxation, and Baker cyst behind the knee. The disease spares the DIP. X-ray findings include soft tissue swellings, joint space narrowing, and bony erosions. The disease has a strong association with HLA-DR4. Rheumatoid arthritis is also associated with pleuritis and pericarditis. Affected joints are typically tender and warm. The most specific test is anti-CCP antibodies. Joint aspiration will reveal WBC >2000/μL and neutrophils between 60% and 80%. Treatment of choice is with disease-modifying antirheumatic drugs (methotrexate, sulfasalazine, and tumor necrosis factor inhibitors) as early as possible. Other treatment options include analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs).

When a resident physician is negligent, it is most often the attending (supervising) physician who is held responsible for direct negligence in failing to provide proper supervision. Due to the Supreme Court's decision in ------ the attending physician can be vicariously responsible for resident negligence under the borrowed servant doctrine.

Rouse v. Pitt County Memorial Hospital,

A 67-year-old male with a history of small cell lung cancer presents to your office for routine follow-up. Routine labs show: urine sodium is 45 urine osmolality is 410 what is the most likely diagnosis?

SIADH The most likely diagnosis is syndrome of inappropriate antidiuretic hormone secretion (SIADH). SIADH in small cell carcinoma is due to the direct production of antidiuretic hormone (ADH) by the tumor cells. SIADH is a common cause of euvolemic hyponatremia that results from stimulated ADH release independent of serum osmolality. SIADH is associated with head injuries, brain tumors, sarcoidosis, pneumonia, paraneoplastic syndromes, small cell lung cancer, and certain antidepressants. The diagnosis can be made based on a urine osmolality greater than 100 mOsm/kg (as in hyponatremia, generally the issue is excess free water, which the kidney should be excreting) with concurrent serum hyposmolarity. The general caveat is that this finding is in the absence of a physiologic reason for increased ADH secretion, such as congestive heart failure (CHF), cirrhosis, or hypovolemia. A urinary sodium greater than 30 mEq/L demonstrates that the patient is not hypovolemic, and is inappropriate for the low serum sodium as the kidney should be attempting to retain sodium at the expense of free water. Addressing the underlying cause and fluid restriction are the mainstays of treatment. If the patient is severely hyponatremic, normal saline or 3% normal saline may be cautiously infused while observing for signs of central pontine myelinolysis. Demeclocycline can help normalize serum sodium by antagonizing the action of ADH in the collecting duct. Tolvaptan is a vasopressin antagonist that can be used in refractory cases.

Salicylate toxicity causes both a metabolic acidosis and respiratory alkalosis.

Salicylate toxicity causes both a metabolic acidosis and respiratory alkalosis. Salicylate toxicity is unique in that it leads to 2 acid-base disturbance mechanisms. Symptoms of salicylate toxicity include nausea, vomiting, abdominal pain, lethargy, tinnitus, dizziness, hyperthermia, tachypnea, hypokalemia, hypoglycemia, altered mental status, seizure, cerebral edema, and coma. There are 3 phases to salicylate toxicity: Phase 1: Hyperventilation resulting from direct respiratory center stimulation leading to respiratory alkalosis and compensatory alkaluria. Potassium and sodium bicarbonate are excreted in the urine. This phase may last up to 12 hours. Phase 2: Paradoxic aciduria in the presence of continued respiratory alkalosis because potassium has been lost from the kidneys. This phase begins within hours and may last 12 to 24 hours. Phase 3: Dehydration, hypokalemia, and progressive metabolic acidosis. This begins 4 to 6 hours after ingestion in a young infant or 24 hours or more after ingestion in an adolescent or adult. There is no specific antidote to aspirin toxicity. The treatment after the overdose has been digested is intensive supportive care, electrolyte imbalance correction, and correction of metabolic derangements.

-----is caused by Group A Streptococcus. Patients present with sandpaper-like rash, circumoral pallor, strawberry tongue, Pastia's lines and skin desquamation.

Scarlet fever Other physical examination findings include Pastia's lines, which are bright red in the creases of the underarm and groin. Once the fever subsides, patients have desquamation of the skin. Treatment of choice is penicillin to prevent the onset of rheumatic fever.

Scleroderma renal crisis

Scleroderma renal crisis is a common presentation of scleroderma and occurs early in the disease course. It is caused by fibroproliferative changes to the small vasculature of the arterial system, resulting in severe hypertension. Malignant hypertension with encephalopathy or retinopathy due to obliteration of the small arterioles and glomerular destruction is a common presenting complaint of scleroderma. The patient's headache is a manifestation of her hypertension and is concerning for possible hypertensive emergency. Although her neurologic exam is normal at this time, untreated, symptomatic hypertension can result in significant morbidity and mortality. The diagnosis of scleroderma renal crisis is a diagnosis of exclusion but should be suspected if signs of scleroderma are present in addition to new-onset hypertension and a rise of >50% in the serum creatinine. Once present, untreated scleroderma renal crisis leads to end-stage renal disease within 1 to 2 months. The most important initial therapy is prompt blood pressure control before irreversible damage has occurred to the renal system. The optimal antihypertensive agent in the setting of renal failure to due to scleroderma is actually an angiotensin-converting enzyme (ACE) inhibitor. It is one of the rare times in which an ACE inhibitor should be used in the setting of new acute kidney injury.

There are two major forms of AAA repair, open surgery or endovascular repair (EVAR). There are currently no differences in mortality between the two types of repair. The cause of an AAA is incompletely understood but is felt to be secondary to degradation of the tunica media by imbalance between matrix metalloproteases and their inhibitors. This leads to weakening of the aortic wall and dilation of the vessel. As the vessel dilates, wall stress increases according to Laplace's Law, leading to eventual wall failure and rupture.

Screening for AAA in men over the age 65 results in a decreased risk of AAA-related mortality; however, for people with a low risk for AAA, any absolute benefit on overall mortality is likely to be small. A one-time screening for AAA is recommended for men ages 65 to 75 who have smoked and in men ages 65 to 75 who have never smoked but who have a first-degree relative who required repair of an AAA or died from a ruptured AAA. Screening for women and other subsets should be individualized, but screening in women who have never smoked is currently not recommended by the United States Preventative Services Task Force (USPSTF).Below is a CT abdomen showing an AAA. The measurements are attached. The edges of the aorta appear white because of advancing atherosclerosis with calcification. As you can see, this is defined as a AAA by the size, which is greater than 3.0cm.

----is caused by vitamin C deficiency, which manifests as collagen defects, abnormal bone growth, bleeding gums, and hemarthrosis. Treatment is focused on vitamin C replacement and is urgent because of the risk for sudden death if the deficiency worsens or goes untreated.

Scurvy

A healthy 24-year-old female with history of asthma should receive the seasonal flu vaccine, the HPV vaccination in a three-part series, and a tetanus booster every ten years. Always consider other vaccinations that might be indicated considering past medical history. Also consider special risk factors such as going to college, a military recruit, etc.COMBANK Insight : Preventative medicine is huge on the COMLEX. Getting a copy of the CDC charts on immunizations for pediatrics and adults and reviewing them the day before the test will get you some easy points on test day.

Seasonal flu vaccine is recommended annually for all persons 6 months or older. If the patient is a healthy, non-pregnant adult below 50 years of age without high-risk medical conditions, they are eligible to receive the live attenuated version intranasal; other patients should receive inactivated vaccine.Tetanus/diphtheria/pertussis (Tdap) is recommended as a one-time dose for adults below 65 years of age who have not received it or if their vaccination status is unknown, with a booster vaccination every ten years. Our patient's last vaccinations were 14 years ago, making her due for a tetanus booster; at this point she should have a one-time Tdap. Patients over 65 years of age should receive the Td (tetanus/diphtheria) booster every ten years.The HPV vaccine (quadrivalent or bivalent) is recommended for females from 11-26 years of age. It is best administered before initiation of sexual contact; however, all females should still be vaccinated in following with age-based recommendations. It is also recommended for males 9-26 years of age in order to decrease the risk of obtaining genital warts.Pneumococcal vaccination is recommended in this patient because of her history of asthma, a chronic lung disease. Pneumococcal vaccination is indicated for any person with chronic lung/cardiovascular/liver disease, diabetes mellitus, cirrhosis, alcoholism, asplenia, immunocompromise, cochlear implants, CSF leak, or HIV.This patient requires a single dose of meningococcal as well because she is an unvaccinated college student living in the dormitory for the first time. Others who need a one-time dose would be military recruits and persons who live/travel in endemic countries.

Sensitivity is the probability that a screening test will be positive in patients with a disease, calculated as:

Sensitivity is the probability that a screening test will be positive in patients with a disease, calculated as: (True Positive) / [(True Positive) + (False Negative)].

Fever and flank pain in the setting of urinary tract infection indicates that the patient has progressed to pyelonephritis. Pyelonephritis is an infection of the renal parenchyma generally due to migration of bacteria up the urinary tract. This can be a life-threatening condition which requires adequate and timely treatment. The symptoms of pyelonephritis can include fever, flank pain, nausea and vomiting, and gross hematuria, associated with the classical symptoms of lower urinary tract infection: frequency, urgency, dysuria, and suprapubic tenderness. Pyelonephritis can be diagnosed by clinical suspicion alone as long as the history is consistent with the above presentation. Due to the risk of morbidity and mortality, any patient with pyelonephritis should undergo urine culture, as resistance may lead to failed treatment and significant complications. Imaging can help confirm the diagnosis, but is not always necessary unless there is concern for other pathology of the urinary tract, such as impacted stone. Surgical consultation is warranted in the case of renal abscess, obstructive or significant calculi, and papillary necrosis.

Signs of sepsis, flank pain, and the symptoms of a urinary tract infection is diagnostic of pyelonephritis.

Small-cell carcinoma of the lung is composed of sheets of small, round cells with scant cytoplasm and fine granular chromatin. Oat cell lung cancer is thought to arise from Kulchitsky cells and is peribronchially located in the chest.

------ is the single most common organism associated with exogenous endophthalmitis.

Staphylococcus epidermidis There are 2 different types of endophthalmitis, exogenous and endogenous. Exogenous refers to inoculation of bacteria from an outside source, mainly trauma or surgery. Endogenous refers to inoculation of the eye from an internal or bloodborne source, such as bacteremia or fungemia. The single most common cause of exogenous endophthalmitis (70% of cases) is Staphylococcus epidermidis, which is typically normal flora of the skin and conjunctiva and generally introduced into the eye during surgical procedures. The second most common is Staphylococcus aureus, at about 10% of cases. On the other hand, endogenous endophthalmitis is most commonly caused by bacteremia and is extremely rare. It is generally associated with endocarditis, and whatever organism is isolated in the blood is likely present in the eye, whether it be Staphylococcus or fungus. In some Asian countries where liver abscesses are common, endophthalmitis can be caused by gram-negative organisms such as Klebsiella. The most common bacterial cause of endogenous endophthalmitis in the United States is S aureus followed by various streptococci and gram-negative organisms.

A lipoma is a benign fatty tumor. Lipomas are uncommon in the hand and would not cause catching or locking of the digits because they are superficial to the flexor tendons.Bottom Line: Trigger finger presents as a painless nodule near the metacarpophalangeal joint and can cause locking or catching of the digits. Conservative treatments are attempted before corticosteroid injections or surgery.

TRUE

All nonsteroidal anti-inflammatory drugs (NSAIDs) should be discontinued in the setting of an upper GI bleed secondary to peptic ulcer disease. A non-NSAID pain medication such as acetaminophen can be used as a substitute in order to relieve the patient's low back pain. NSAIDs induce peptic ulcer disease through disruption of the prostaglandin pathway. This is a class effect.Oral proton pump inhibitors (PPIs) should be initiated in all patients with an upper GI bleed after esophagogastroduodenoscopy in order to reduce the risk of rebleeding in peptic ulcers and should be continued for 4-8 weeks. High-dose oral or intravenous PPIs may be used though IV is generally preferred for severe bleeding in the acute period and is then transitioned to oral. In a recent study, IV bolus was compared to drip and was non-inferior. PPIs were also studied head to head against H2 blockers and were found to be superior.Bottom Line: For prevention of recurrent GI bleeds, the patient will need to stop all nonsteroidal anti-inflammatory drugs. Every patient presenting with upper GI bleeding due to peptic ulcer disease should be discharged on an oral proton pump inhibitor.

TRUE

Although this patient falls into the high-risk category, the procedure does not. Using the above table as a reference guide, this does not satisfy the criteria of both high-risk patient and high-risk procedure. The IDSA specifically states that radiographic studies, adjustment of appliances, shedding of deciduous teeth, or any other procedure not involving the mucosa, gingiva, or periapical regions do not require antibiotics. Current guidelines from the Infectious Diseases Society of America (IDSA) clearly distinguish which patient risk factors and which procedure combinations necessitate antibiotic prophylaxis to help prevent endocarditis. To require antibiotic prophylaxis, the situation must involve both a high-risk patient and a high-risk procedure. Antibiotic regimens usually include amoxicillin or, if the patient is penicillin allergic, cephalexin, clindamycin, or azithromycin.

TRUE

An incomplete fracture is characterized by a portion of the cortex still being intact. This is more common in children who have softer bones and is manifested by a lucency that does not extend to the opposite cortex. The majority of incomplete fractures will be non-displaced since part of the cortex of the bone is still intact.

TRUE

An ultrasound of the eyeball is useful for determining retinal detachment, vitreous hemorrhage, and measuring optic nerve diameter for increased intraocular pressure.

TRUE

Bottom Line: Three sets of aerobic blood cultures should be drawn immediately when infective endocarditis is suspected.

TRUE

CT abdomen and pelvis with IV contrast is not the best answer in this patient. The indications for a CT with contrast would include evaluation and staging of renal cell carcinoma or further evaluation of a renal mass or cyst visualized on ultrasound

TRUE

CT of the abdomen and pelvis with contrast is the current gold standard imaging test for acute appendicitis in an adult and should always be considered as the first test if the patient's condition and renal function allow. It gives good information about all of the anatomical structures within the abdomen and pelvis, including the appendix, liver, pancreas, kidneys, biliary system, ovaries, and uterus, and the use of contrast will allow the detection of even small amounts of inflammation or abscesses. Oral contrast should be used to outline the internal border of the abdominal viscera, including the appendix, because scans without oral contrast can sometimes result in difficulty locating the appendix, requiring secondary testing and wasted resources.If a CT scan is performed, no other imaging would be immediately necessary, and ordering other tests would be a waste of resources.

TRUE

Cauda equina syndrome may result from any lesion that compresses cauda equina nerve roots. These nerve roots are particularly susceptible to injury because they have a poorly developed epineurium. A well-developed epineurium, as peripheral nerves have, protects against compressive and tensile stresses. Cauda equina syndrome is caused by any narrowing of the spinal canal that compresses the nerve roots below the level of the spinal cord. Numerous causes of cauda equina syndrome have been reported, including disc herniation, intradural disc rupture, spinal stenosis secondary to other spinal conditions, traumatic injury, primary tumors such as ependymomas and schwannomas, metastatic tumors, infectious conditions, arteriovenous malformation or hemorrhage, and iatrogenic injury. Distinguishing cauda equina syndrome from conus medullaris is important. Investigation with a magnetic resonance scan of the lumbar spine is indicated.

TRUE

Cerebral edema and death are possible and well documented if an athlete suffers a second impact before recovering from the initial concussion, a phenomenon known as second-impact syndrome. Some debate exists over whether a single impact may, in some cases, be enough to cause edema. A second hit places the patient at much higher risk, especially among teenage athletes.

TRUE

DEXA scans are not routinely recommended in men. The USPSTF recommends a DEXA scan in postmenopausal women younger than 65 who are at increased risk for osteoporosis and in all women over the age of 65.

TRUE

In any patient with BPH and renal insufficiency (elevated creatinine) radiographic evaluation of the renal system should be considered. This is best accomplished with a renal ultrasound which will evaluate for any signs of bladder outlet obstruction or hydronephrosis which can be a common complication of untreated BPH. An ultrasound gives the best imaging without the concomitant risk of radiation exposure and is a cheaper initial test. In urinary tract obstruction, there is an initial increase in pressure proximal to the obstruction due to continued glomerular filtration, which is eventually responsible for the dilatation of the collecting systems. Continued back-up of urine into the collecting system and proximal tubules results in renal injury and elevated creatinine. If detected early, decompression with intermittent straight catheterization or placement of a foley catheter will restore renal function to normal.

TRUE

Isotonic fluids are appropriate as the initial management in preload-dependent states including cardiac tamponade, septic shock, and hypovolemic shock. Generally, any patient who presents with shock will be initially managed with some kind of fluids. This, however, is not the definitive management of this patient. Fluids are a temporizing measure until the pericardial fluid can be removed.

TRUE

Needle thoracostomy is the lifesaving treatment for a tension pneumothorax, which is not suggested by the physical exam. Decreased breath sounds and trachea deviation are present with a tension pneumothorax. This patient has distended neck veins, consistent with pericardial tamponade.

TRUE

Papillary thyroid cancer is the most common type of thyroid cancer. It is often well-differentiated, slow-growing, localized and carries a favorable prognosis, even if metastasis has occurred as growth can often be controlled with ablation and TSH suppression.

TRUE

Patients presenting with an upper GI bleed should have 2 large-bore IVs placed, preferentially 16 or 18 gauge lines as these allow significant flow. In general, flow through IV lines follows Poiseuille's Law: the flow through an IV line is related to the viscosity of the fluid, the pressure gradient across the line, as well as the line's resistance which are determined by the length of the line and the diameter. In patients requiring significant resuscitation, this can be accomplished by using large diameter IVs with the shortest tubing available with fluid infused using a pressure bag.Any patient presenting with instability and bleeding should be resuscitated using fluids, either crystalloid or colloid, mainly normal saline or lactated ringers solution in addition to blood products. Restoring circulating volume and maintaining blood pressure should be the initial first priority in any unstable patient. In patient's with upper gastrointestinal bleeding, IV proton pump inhibitors should be initiated, either as a drip or as bolused pushes depending on hospital policy. They have been shown to be equally as effective.Generally accepted transfusion thresholds are < 7 g/dL for hemodynamically stable adults, even those in critical care, and < 8 g/dL for patients with preexisting cardiovascular disease or those undergoing cardiac or orthopedic surgery.An NG tube can be placed for lavage, though there is little doubt that this is an upper GI bleed given his melena and low hemoglobin. An upper endoscopy should be performed in all patients who present with upper GI bleeding within 24 hours of hospitalization. Patients with continued active hemorrhage should be stabilized before endoscopy if possible. If endoscopy is not feasible, embolization with interventional radiology is a second option. Endoscopy is the preferred approach and is diagnostic, prognostic and therapeutic.

TRUE

Retropharyngeal abscess (RPA) causes the symptoms of sore throat, fever, neck stiffness, and stridor. These symptoms are similar to those of epiglottitis. However, these symptoms occur more gradually than epiglottitis which tends to occur abruptly. A retropharyngeal abscess occurs much less commonly today than in the past because of the widespread use of antibiotics for suppurative upper respiratory infections. Radiographically, retropharyngeal space edema will manifest as widening of the prevertebral soft tissues. There will be an abscess in the posterior pharyngeal wall.

TRUE

Rett syndrome is a hereditary intellectual disability that only affects girls. It has no association with ADHD. Young girls may develop normally and then experience extreme regression in learning and social skills. Repetitive hand wringing is typically associated with this syndrome.

TRUE

Screening intervals and guidelines are commonly tested on the COMLEX. According the USPSTF, women should have their first pap smear at the age of 21 and then every 3 years thereafter as long as there are no significant abnormalities. After the age of 30, HPV testing can be added to routine cytology and if normal, the screening interval can be lengthened to every 5 years. This is a grade A recommendation. The USPSTF also recommends against screening women below the age of 21 or above the age of 65 and this is a grade D recommendation, meaning there is moderate or high certainty that the harms outweigh the benefits or that there is no net benefit of the service. This is thought to be due to the high incidence of HPV in the population of women aged less than 21. Most people will clear this infection, however, during the infective and clearance periods, there can be abnormalities seen on pap testing and colposcopy which can lead to more invasive procedures. The natural history of the disease dictates that the majority of women will resolve these issues in their teenage years without issue and that the development of cervical cancer does not generally occur until much later. Self-breast exams are no longer recommended by the USPSTF and are also a grade D recommendation. This is due to increased harms associated with increased unnecessary testing. Self-breast exams should not be recommended at this office visit.

TRUE

The diagnosis of a Chiari malformation is based entirely upon imaging. There are no biomarkers or blood tests available which can confirm the diagnosis. MRI is the preferred neuroimaging study of choice. In general, imaging of the brain, as well as images of the entire spinal cord using T1 and T2 weighted MRI, are useful for detecting cerebellar and brainstem changes. The same imaging modalities would also be able to detect changes at the cranial cervical junction and syringomyelia. If there is a concern for bony abnormalities, then a CT scan can be performed with reformatted images. If the patient is unable to perform an MRI, then a CT scan would be the next study of choice. The diagnosis is officially made when there is displacement of the cerebellar tonsils by greater than 5 mm below the foramen magnum. If the displacement is less than 5 mm, then there must be associated signs and symptoms consistent with Chiari malformation.There are 3 types of Chiari malformation with type 3 being quite rare and uncommon. Type 1 is generally associated with syringomyelia at a rate of 40-75%. There are reports of holocord syrinx that extends the entire length of the spinal cord. A Curet type 2 malformation is generally associated with a myelomeningocele at the lumbosacral spinal cord.

TRUE

Patients on positive-pressure ventilation are at risk for baro and volutrauma, collectively known as barotrauma and a simple chest radiograph should be performed if this is suspected.

The above scenario describes an intubated patient with acute agitation and oxygen desaturation. The most appropriate study to order is a chest radiograph. Any patient receiving positive pressure ventilation is at risk for pneumothorax as well as volume and pressure induced barotrauma to the lungs. This barotrauma causes the development of ventilator-induced lung injury and is especially damaging in patients with underlying acute respiratory distress syndrome. The barotrauma is caused by baro and volutrauma to the alveolar sacs causing membrane rupture and development of hyaline membranes and inflammatory mediators. Treatment is with low tidal volumes for mechanical ventilation.

The patient is due for a variety of screening tests: The USPSTF recommends screening for colorectal cancer from age 50-75 for all adults. Options for screening include annual testing with FIT, every 10 years with a flexible sigmoidoscopy combined with an annual FIT, screening every 3 years with Cologuard (FIT-DNA), colonoscopy every 10 years, or CT colonoscopy every 5 years. Colonoscopy has found to be the most effective with diagnosing and treating lesions. The USPSTF recommends a one-time screening for abdominal aortic aneurysm with ultrasound in men ages 65-75 who have ever smoked. 100 cigarettes or more is commonly used to define "have ever smoked." The USPSTF recommends annual screening for lung cancer with a low dose CT in adults ages 55-80 who have a 30-pack-year smoking history and currently smoke or have quit within the past 15 years. Of note: PSA testing could be considered if the patient has risk factors for prostate cancer, but should be a risk-benefit discussion between the physician and patient. It is not recommended for everyone.

TRUE

The patient presents with psoriasis, an immune-mediated skin disease characterized by erythematous plaques with overlying silvery scale and sharply defined margins. The lesions are typically asymptomatic and involve the knees, elbows, gluteal cleft, and scalp. There may also be associated nail pitting and onycholysis (lifting of the nail). Patients with psoriasis can develop Koebner phenomenon (development of lesions in areas of trauma). If psoriasis lesions are picked, it can lead to bleeding (known as Auspitz sign). Additionally, psoriasis can be associated with an inflammatory arthritis of the joints known as psoriatic arthritis. Treatment involves topical corticosteroids, topical vitamin D analogs, and topical retinoids for limited disease. For disease involving greater than 30% body surface area, as described in this scenario, treatment with ultraviolet (UV) light, such as UVB or psoralen and UVA (PUVA), is indicated. For patients with moderate to severe or refractory disease, treatment with biologic immune-modifying agents (eg, adalimumab, etanercept, infliximab) may also be indicated. Although systemic corticosteroids are excellent at controlling and limiting psoriasis plaques, the use of systemic corticosteroids is not recommended because this almost always results in severe rebound disease, which can sometimes be worse than before systemic steroids were initiated.

TRUE

Prophylactic broad-spectrum antibiotic eye drops are recommended in the treatment of postoperative corneal abrasion.

TRUE An antibiotic for contact lens wearers would be ciprofloxacin. For patients who do not wear contact lenses, erythromycin is adequate. Ointments are preferred over drops as they provide lubrication. There is not good evidence whether the antibiotics prevent infection or shorten the time to healing, but they are often clinically used in practice and are currently recommended. Additionally, antibiotics should not be combined with steroids. Steroids are contraindicated in the setting of corneal abrasions as they slow healing and can reduce resistance to infection. Indications for emergent OPTHO consultation include: A larger epithelial defect Purulent discharge A drop in vision of more than one to two lines on a Snellen chart (eg, drop from 20/20 [6/6] to 20/80 [6/24]) Corneal abrasion that has not healed after three to four days

Effectiveness of benzodiazepines in insomnia is attributed to its effect of increasing the frequency of chloride channel opening on gamma-aminobutyric acid type A (GABA) receptors. This results in a net GABAergic response and subsequent sedation. Benzodiazepines have been used in the treat sleep latency insomnia since the 1970's and has notable effects on the sleep cycle. While effective at decreasing time to onset sleep its prolongation of total sleep time is primarily though increasing stage 2 of sleep. It is known to decrease time spent in the deeper and more restful stages 3 and REM. Also notable are the myriad of adverse effects associated with benzodiazepines. These include but are not limited to; tolerance, dependence, rebound insomnia, increased delirium, increased risk for the development of dementia, respiratory depression when combined with other medications, and an increased risk for all cause mortality.Benzodiazepines are a hot topic currently as multiple new studies over the past 5 years have shown significant adverse short and long-term events. In the references below are recent publications emphasizing this. Benzodiazepines are however effective and have multiple uses. They may be considered for short term treatment of insomnia (usually 2-4 weeks). In general, patients should reassess their sleep habits - avoiding caffeine late in the day, limiting electronics (TV, computer, tablets) in the bedroom, and avoiding alcohol late in the evening. These should always be the best initial interventions both on tests and in real life.

TRUE Benzodiazepines may cause respiratory depression in susceptible individuals, and are therefore contraindicated in patients with myasthenia gravis, sleep apnea, and COPD. Bottom Line: Cauda equina syndrome presents as a gradual, unilateral (occasionally bilateral) sciatica with saddle anesthesia.COMBANK Insight : No proven medical treatment exists, and therapy generally is directed at the underlying cause of cauda equina syndrome. For penetrating trauma, steroids have not shown significant benefit.

The most likely diagnosis is pancreatic cancer. In any patient presenting with weight loss and painless jaundice, this should be the first condition on the differential diagnosis. More than 50% of pancreatic cancers are adenocarcinomas that involve the head of the pancreas. Risk factors include chronic pancreatitis, smoking, high-fat diets, age over 45, male gender, and a first-degree relative with pancreatic cancer. It classically presents with painless, progressive obstructive jaundice. It may also present with abdominal pain that radiates toward the back, indigestion, fatigue, loss of appetite, weight loss, or nausea and vomiting.Pancreatic cancer is often asymptomatic and presents late in the disease course. Physical exam may reveal Courvoisier sign and/or Trousseau sign. Courvoisier sign is a non-tender, palpable gallbladder, whereas Trousseau sign is a migratory thrombophlebitis. The best initial screening test is a CT scan of the abdomen, which may reveal a pancreatic mass, dilated pancreatic and bile ducts, hepatic metastases, or vascular involvement.If a mass is not appreciated with CT scanning, an ERCP may be used to confirm the diagnosis. ERCP is the best test and considered first line for confirming the diagnosis, because the majority of these cancers result in narrowing of the common bile duct, which can be seen with biliary contrast injection. At the same time, ERCP allows for brushings to be obtained for cytology. MRCP is an non-invasive imaging method used to visualize the hepatic and biliary systems, but it does not allow for tissue sampling. Endoscopic ultrasound may be used for better visualization of potential masses. However, this requires more specialized equipment and practitioners and is generally not performed initially unless ERCP is negative and the clinical suspicion for pancreatic cancer remains high.Most patients with pancreatic cancer present with metastatic disease, and therefore treatment is palliative. If there is a large mass seen on CT, then oftentimes the patient may go for surgical biopsy with resection if they are a surgical candidate rather than EUS with biopsy. Approximately 10-20% of pancreatic head tumors that have no evidence of metastasis or major vessel involvement may be treated with a pancreaticoduodenectomy, also known as the Whipple procedure. Chemotherapy with 5-FU and gemcitabine may improve short-term survival, but the long-term prognosis is poor.

TRUE Bottom Line: ERCP is the best test for confirming the diagnosis of pancreatic cancer for two reasons. One, it is readily available to most gastroenterologists and at most centers, unlike EUS. Secondly, it can be used to obtain images of the pancreatic ducts, which can reveal malignant strictures, as well as to obtain brushings with cytology. If ERCP is suspicious for stricture but not obvious, and cytology is negative, then EUS can be obtained to better visualize the pancreas. If clinical suspicion remains high despite a negative ERCP, then EUS can also be obtained to evaluate for very small pancreatic lesions. If ERCP is positive, then the patient should be referred for a specialized staging CT of the pancreas. If the patient is a surgical candidate, then they should go for operative resection rather than biopsy. If they are not a surgical candidate, then they would be referred for EUS and biopsy.

Complete blood count (CBC) should be performed for evaluation of WBC count and hemoglobin/platelet levels if surgery is going to be considered. In this young patient without other issues, the CBC/platelet values will almost certainly be near normal; however, the WBC count may be significantly elevated due to infection. A basic metabolic panel and liver profile will evaluate liver function, which is likely normal because she is not jaundiced or showing signs of severe sepsis, as well as renal function, which is also expected to be normal. If she has an elevated creatinine, it would be a sign of a more severe infection than previously thought or an alternative etiology for her abdominal pain, such as nephrolithiasis within the ureter. She may also have electrolyte disturbances that need to be corrected before surgery could be considered. Lactic acid in the setting of abdominal infection and sepsis is a marker of severity and can be tracked as treatment is initiated. High levels of lactic acid with a high WBC count would be more concerning for severe sepsis and possible perforation.A urinalysis should be considered on any patient with nonspecific abdominal pain because bladder pain can sometimes be generalized. This could also be the pain of a migratory stone in one of the ureters, although generally, peritoneal signs would not be present. A urinalysis with high WBC count and leukocyte esterase would be concerning for urinary tract infection and pyelonephritis, and if, in the setting of a positive urinalysis and infectious symptoms, a renal stone was found within the ureter on imaging, then urology would need to be consulted for possible stenting or extraction. A pregnancy test should be performed on all women of child-bearing age who present with abdominal pain because it will significantly alter the differential if positive and prevent the use of certain imaging modalities except in great duress.

TRUE Bottom Line: The initial workup of a patient presenting with generalized abdominal pain and signs of sepsis should at least include a basic metabolic panel with electrolytes and creatinine, complete blood count, urinalysis, pregnancy test, and lactic acid.

The most likely diagnosis in this patient is an Achilles tendon rupture. An Achilles tendon rupture results in sudden pain in the superior heel. The Thompson test is positive in this patient. The Thompson test is performed with the patient prone on the exam table; the gastrocnemius muscle is squeezed, and the foot should plantar flex if the Achilles tendon is intact. A lack of plantarflexion when the gastrocnemius is squeezed is considered a positive test and indicates a compromised Achilles tendon.

TRUE Patients with aPL antibody syndrome need lifelong anticoagulation with warfarin. Complications associated with SLE include a higher incidence of spontaneous abortion, increased risk of developing congenital complete heart block in infants with mothers with SLE, increased risk of arterial and venous thromboses secondary to aPL antibody syndrome, and increased mortality due to accelerated atherosclerosis, infection, malignancy, and renal disease.

Corneal abrasion is the most common ophthalmic complication in patients undergoing surgery under both general anesthesia and monitored anesthesia care. Superficial abrasions are limited to the corneal epithelium, although severe injuries may also involve the deeper, thicker stromal layer. The most common intraoperative and postoperative cause of corneal abrasions is due to patients rubbing their eyes during emergence from general anesthesia or while in the postanesthesia care unit. During the surgery, anything brushing against the open eye (eg, drapes, endotracheal tube, laryngoscope, facemask) may subject the eye to microtrauma. Common symptoms of corneal abrasion include photophobia with spared visual acuity. Blepharospasm may also be present. Look for bulbar conjunctival injection on physical examination, which is noted in this case.

TRUE Slit lamp examination is the best test for the diagnosis of corneal abrasion. Cycloplegic agents such as homatropine should be used prior to examination in patients suffering from blepharospasm due to severe photophobia.

Cost-effectiveness research aims to estimate the monetary cost required to gain a specific health benefit.

TRUE The goal of a cost-effectiveness analysis is to determine the monetary cost per quantity of health obtained. This is most often expressed in quality years of life but can refer to the cost in dollars per any number of measurements of health, including head bleeds detected.

The patient has acute, adult-onset epiglottitis with airway obstruction. Epiglottitis is an acute inflammation in the supraglottic region of the oropharynx with inflammation of the epiglottis, vallecula, arytenoids, and aryepiglottic folds. In the United States, epiglottitis is an uncommon disease with an incidence in adults of about 1 case per 100,000 per year. Adult epiglottitis is most frequently a disease of men occurring during the fifth decade of life. Symptoms occur abruptly. Historically, acute epiglottitis was most common in children aged 2-4 years. In a 2005 retrospective review of patients with acute epiglottitis, symptoms of stridor, voice muffling, rapid clinical course, and a history of diabetes mellitus were significantly associated with the need for airway intervention. On an X-ray, epiglottitis is identified by "thumb sign." This is noted when the epiglottis juts out into the airway like the end of a thumb. You can see the edge of the epiglottis outlined in the image below using a yellow line. A normal epiglottis should be a very thin sheet of connective tissue rather than a large, bulbous knob as shown. Ideally, patients with epiglottitis would have a culture performed to guide antibiotic management. Empiric therapy should be targeted towards Haemophilus influenzae type b, Streptococcus pneumoniae, including strains that may be penicillin-resistant, Group A Streptococcus, and Staphylococcus aureus, including MRSA. This would generally require vancomycin in addition to a third-generation cephalosporin such as ceftriaxone.

TRUE Although epiglottitis is most common in children from 2-7 years of age, be prepared for the examination to throw you a curve ball, such as this question. Acute epiglottitis may manifest with symptoms of stridor, voice muffling, and a rapid clinical course. DIFFERENTIATE FROM Retropharyngeal abscess (RPA) causes the symptoms of sore throat, fever, neck stiffness, and stridor. These symptoms are similar to those of epiglottitis. However, these symptoms occur more gradually than epiglottitis which tends to occur abruptly. A retropharyngeal abscess occurs much less commonly today than in the past because of the widespread use of antibiotics for suppurative upper respiratory infections. Radiographically, retropharyngeal space edema will manifest as widening of the prevertebral soft tissues. There will be an abscess in the posterior pharyngeal wall.

Acute upper gastrointestinal bleeds are more common in adults 60 years of age or older; however, they can occur at a younger age when risk factors are present. The most common presentation for upper GI bleeds is melena or hematemesis (bright red or coffee ground emesis). Depending on the severity of the bleed, dizziness, confusion, low blood pressure, increased heart rate, and epigastric pain may also occur. Common causes of upper GI bleeds include peptic ulcers, varices, Mallory-Weiss tears, gastritis (nonsteroidal anti-inflammatory drugs [NSAIDs], alcohol), and vascular abnormalities. Naproxen is a common NSAID given for pain and is the most likely culprit in this case. The initial workup should include a CBC for hemoglobin and platelet count, metabolic panel for electrolytes and creatinine, and coagulation studies to rule out clotting disorders, which can be corrected or will require intervention. A type and screen should be done in case a blood transfusion is necessary, and this should not be delayed until the results from the CBC return. Based on history, this patient has an upper GI bleed, which can lead to severe blood loss. An EKG can be ordered to exclude arrhythmias and cardiac disease, especially acute myocardial infarction due to hypotension, if there is clinical concern. Alcohol is a common cause of upper GI bleeds, and if chronic alcohol use or acute alcohol ingestion is suspected then liver function tests can be ordered; however, in the setting of low suspicion for alcoholic liver disease, liver function tests are not part of the initial workup and would have limited utility in this case.

TRUE Bottom Line: Initial evaluation for an acute upper GI bleed would include ordering the following: CBC, metabolic panel, type and screen, and coagulation studies.

The -------This act provides rules and laws regarding length of stay in the hospital for a newborn and the mother.

The NMHPA is the Newborn Mother's Health Protection Act. This act provides rules and laws regarding length of stay in the hospital for a newborn and the mother.

The National Practitioner Data Bank is aimed at

The National Practitioner Data Bank is aimed at restricting the ability of physicians to move from state to state without disclosure or discovery of previous medical malpractice payment and adverse action history.

Bottom Line: The anterior cruciate ligament (ACL) is the most commonly injured knee ligament and presents classically with a "pop."COMBANK Insight : When encountering a question with little to no information, always choose the most common answer.

The anterior cruciate ligament (ACL) is the most commonly injured knee ligament and is usually described as a "pop." Aside from direct trauma, nearly all ACL tears occur from non-contact athletic injuries. Female gymnasts sustain the highest rate of injury. There are currently 5 proposed explanations to account for the gender disparity involving ACL tears, as women sustain significantly higher rates than men, which are: quadriceps-dominant deceleration, increased valgus knee angulation, effects of estrogen, discrepancies in Q angle, and decreased intercondylar notch width. The most sensitive and specific tests to delineate ACL injury are the Lachman, the Pivot Shift, and the anterior drawer.

Bottom Line: Methadone has proved to be effective in treating dependence and withdrawal symptoms associated with opioid addiction. It should be prescribed by a methadone clinic. Patients without acute withdrawal symptoms do not require admission to the hospital and can follow up with their clinic. COMBANK Insight : Methadone, a long-acting synthetic opioid agonist, can be dosed once daily and replaces the necessity for multiple, daily heroin doses. As such, it stabilizes the drug-abusing lifestyle, reducing criminal behaviors, as well as reducing needle-sharing and promiscuous behaviors that lead to the transmission of the human immunodeficiency virus (HIV) and other diseases.

The goal in treating heroin/opioid addiction involves relieving the side effects of withdrawal and reducing cravings. Opioid replacement therapy has shown improved results over abstinence. Medications include buprenorphine and methadone. Methadone is the traditional medication to treat opioid/heroin withdrawal symptoms. It is a long-acting synthetic opioid agonist. It has proved to be effective in treating dependence and withdrawal symptoms associated with opioid substance abuse. However, it has a long half-life, and full agonism can lead to overdose. Buprenorphine is a mu-opioid partial agonist that can prevent cravings and withdrawal symptoms. The partial agonist mechanism gives it a better safety profile and decreases the risk of overdose. It can be combined with opioid antagonists in various concentrations to prevent abuse of the drug. Suboxone provides buprenorphine and naloxone in a sublingual tablet form. The combination prevents the dissolving and injecting the drug by addicts; injecting the drug results in withdrawal symptoms secondary to naloxone. Naloxone has poor sublingual absorption. Methadone clinics have proved not only to reduce addiction rates, but also to reduce opioid-related criminal behavior. Patients in methadone clinics should only receive their medication from that clinic. The patient is without any acute withdrawal symptoms and can follow up with his clinic in the next 24 hours to address his issues.

Palliative care is not the same as withdrawal of all care. If a patient wishes to be placed in palliative care (whether directly verbalized to you or instructed by power of attorney), you must still care for the patient and treat the patient within the constructs of comfort care.

The goal of palliative care is to improve the quality of life with seriously or terminally ill patients, such as the one in the question stem. It is an approach directed towards the patient's comfort rather than the disease itself. Common synonyms are comfort care or symptom management. It is important to recognize that palliative care does not mean the discontinuation of all care, and certain treatments (including surgery) can still be done, so long as the quality of life remains at the forefront of therapeutic goals.The most appropriate next step in the management of this patient is to draw blood cultures and investigate the cause of this likely infection. Minimally invasive treatment options (such as antibiotics) do not go against the tenants of palliative care. In fact, an untreated infection would arguably worsen the quality of life of a terminally ill patient, especially if it is something that can be easily treated.

The most common cause of acute bacterial sinusitis and otitis media in the pediatric population is

The most common cause of acute bacterial sinusitis and otitis media in the pediatric population is Streptococcus pneumoniae, with other common causes being Haemophilus influenzae (nontypeable in vaccinated populations) and Moraxella catarrhalis. Approximately 6% to 13% of viral rhinosinusitis (RS) is complicated by acute bacterial RS, and should be suspected if the infection does not clear in 7 to 10 days.

Arnold-Chiari malformation type 1 can present with progressive headaches and symptoms consistent with the development of a syrinx.

The most common cause of syringomyelia is an Arnold-Chiari malformation. Given that this patient has presented with worsening headaches over the past 6 months, that should raise concern for foreign Arnold-Chiari malformation type 1, which is often seen on imaging as herniation of the cerebellar tonsils through the foramen magnum. This results in obstruction of CSF flow, which causes both the development of a syrinx and chronic headaches. Arnold-Chiari malformation is often present in the 3rd to 4th decade of life and treatment is mainly surgical decompression of the foramen magnum.Syringomyelia is a fluid-filled cavity within the spinal cord itself. As the cavity or syrinx expands, it begins to compress the adjacent neural tissue, which results in disruption of the lateral spinothalamic tracts as they cross over through the center of the spinal cord. This can result in loss of pain and temperature sensation, decreased deep tendon reflexes (DTRs) at the level of the injury, or increased DTRs at the level below the syrinx, and, if the syrinx expands enough to compress the alpha motor neurons, flaccid paralysis, loss of DTRs, and fasciculations.

------- presents with systemic symptoms, and cervical adenopathy in the third or sixth decades.

The most likely diagnosis is Hodgkin lymphoma. Hodgkin disease (HD) is a predominately B-cell malignancy. It may have an association with Epstein-Barr virus (EBV). It usually presents in the third decade or sixth decade. Nodular sclerosing type is the most common type in patients in their 30s, while lymphocyte-depleted type is more common in patients in their 60s. HD usually presents with cervical adenopathy, but it may also present with a mediastinal mass. Early in its presentation it is present above the diaphragm with infradiaphragmatic involvement suggesting more disseminated disease. Other presenting signs include systemic symptoms, pruritus and hepatosplenomegaly. Pel-Ebstein fevers and alcohol-induced nodal pain are rare, but specific signs of Hodgkin disease. Diagnosis is best made with excisional lymph node biopsy, because fine-needle biopsy is usually nondiagnostic. Histology is considered positive when Reed-Sternberg cells are observed, which are abnormal giant cells with bilobar nuclei and eosinophilic nucleoli. The most common subtype of HD is nodular sclerosing type. The Ann Arbor staging system is most widely used, and is based on the number of affected lymph nodes, presence of B symptoms, and whether the disease crosses the diaphragm or not. A staging laparotomy is not usually recommended. Treatment is stage dependent, and usually consists of chemotherapy with or without radiation therapy.

Bottom Line: Etanercept is a recombinant for the human tumor necrosis factor receptor that binds to and inactivates soluble tumor necrosis factor. Etanercept is also considered a human fusion protein monoclonal antibody.

The most likely diagnosis is rheumatoid arthritis, which is a systemic autoimmune disorder characterized by chronic, destructive, inflammatory arthritis with symmetric involvement of both large and small joints that results in synovial hypertrophy and pannus formation, ultimately leading to erosion of adjacent cartilage, bone, and tendons. Risk factors include female gender, age 35-40, and HLA-DR4. It presents with insidious onset of morning stiffness lasting more than an hour, warm and swollen joints, and systemic symptoms such as fever and fatigue. IgM antibodies against the Fc portion of IgG, also known as rheumatoid factor, may be used as a screening tool along with ANA and ESR. The most specific lab for RA is anti-cyclic citrullinated peptide (anti-CCP). RA can be treated with NSAIDs, hydroxychloroquine, sulfasalazine, methotrexate, rituximab, etanercept, infliximab, or adalimumab. Etanercept is a human fusion protein of TNF-a type 2 receptor that binds to and inactivates soluble tumor necrosis factor.

The most likely diagnosis of this patient's symptoms is ------------ The swollen eyes described above are sometimes referred to as "allergic shiners," and the blue nasal mucosa is also characteristic of this condition.

The most likely diagnosis of this patient's symptoms is allergic rhinitis. The swollen eyes described above are sometimes referred to as "allergic shiners," and the blue nasal mucosa is also characteristic of this condition. The best treatment for allergic rhinitis is intranasal steroids to help reduce swelling. If the patient had complaints of itching or sneezing and signs of an allergic response outside the nasal mucosa, then the appropriate intervention would be with the addition of a second-generation antihistamine. Because his complaints are limited to the nose, the appropriate treatment is with a topical nasal steroid. There are 6 types of strains that can occur at the sphenobasilar synchondrosis (SBS): flexion/extension, torsion, sidebending/rotation, vertical strain, lateral strain, and compression. The osteopathic findings stated above describe a lateral strain. A lateral strain of the SBS is present when the sphenoid deviates laterally in relation to the occiput. If the sphenoid deviates to the left, it is termed a left lateral strain. If the sphenoid deviates to the right, it is termed a right lateral strain. Rotation will occur about 2 vertical axes, one through the center of the sphenoid, the other through foramen magnum. Palpation of a lateral strain will feel as if the cranium is shaped like a parallelogram.

Bottom Line: The first-line therapy to treat acute stable angina is sublingual nitroglycerin.COMBANK Insight : Use the osteopathic findings presented to aid in disease recognition, localization, and chronicity. Isosorbide mononitrate is a long-acting nitrate that can be used in patients with exertional stable angina to improve exercise tolerance and time to onset of angina.

The patient above has symptoms of stable angina, which is described as chest discomfort that occurs predictably and reproducibly at a certain level of exertion and is relieved with rest. Quick-acting nitrates (eg, sublingual nitroglycerin) are the first-line treatment for acute anginal symptoms, and patients should be instructed to use them at the onset of pain. Viscerosomatic reflexes are a type of somatic dysfunction caused by changes in the autonomic nervous system. They can be acute or chronic and are considered to be a somatic representation of visceral disease. When either branch of the autonomic nervous system (sympathetic or parasympathetic) overstimulates a particular organ, a reflex reaction occurs. The soma at the same level of the organ's autonomic innervation takes on characteristics of somatic dysfunction (TART [tenderness, asymmetry, restricted motion, and tissue texture changes]). T1-T5 is where the sympathetic viscerosomatic reflex for the heart is located. The osteopathic findings described also illustrate chronic findings in somatic dysfunction, in contrast to acute changes. Acute and chronic somatic dysfunction findings differ in tissue texture changes, restriction, and tenderness. In patients with chronic somatic dysfunction, the tissue texture changes are cool, dry, flaccid, ropy, and fibrotic. The restriction is present, but there is decreased or no pain. Tenderness in chronic somatic dysfunction is described as dull, achy, and burning. Acute tissue texture changes are edematous and erythematous, with increased tonicity of muscles. The restriction is present and is painful with movement. Acute tenderness is described as severe and sharp.

Bottom Line: Intubation and intravenous antibiotic therapy are required for patients suffering from airway compromise secondary to epiglottitis.COMBANK Insight : Another clinical scenario of epiglottitis may present you with the following picture with the classic "thumb-print" sign.

This patient is demonstrating symptoms consistent with epiglottitis and is in respiratory distress. Nasotracheal intubation in the operating room and intravenous (IV) antibiotic therapy are recommended for children suffering from this diagnosis.Rib dysfunctions are a type of somatic dysfunction in which movement or the position of a rib is altered or disrupted. This can be seen with a single rib, or it can be a group dysfunction. In a group dysfunction, there is usually one rib that is responsible for causing the dysfunction, referred to as the "key rib." This particular case is describing an exhalation dysfunction. In an exhalation dysfunction, the dysfunctional rib(s) will move caudad during exhalation; however, the dysfunctional rib(s) will not move cephalad during inhalation. The rib will appear to be "stuck down." In ribs with bucket handle motion (ribs 6-10), there will be lateral narrowing of intercostal space below the dysfunctional rib in an exhalation dysfunction. Lastly, in a group exhalation dysfunction, the key rib is the uppermost rib (in this case, rib 6 on the right).

Bottom Line: Congestive heart failure (CHF) leads to hypervolemic hyponatremia, which causes the body to conserve sodium. In addition, CHF leads to increased sympathetic activity, which in turn leads to renal vasoconstriction. This leads to increased antidiuretic hormone, angiotensin II, and norepinephrine release, causing the kidneys to limit both sodium and water excretion. Almost all patients with acute CHF will be hypervolemic. Whether or not they manifest with hyponatremia generally has to do with the ratio of salt to free water intake and their respective renal functioning. Moderate to severe hyponatremia (Na <125 mEq/L) in the setting of heart failure is generally considered a poor prognostic sign.

The patient is presenting with overt signs and symptoms of congestive heart failure. Heart failure impairs the ability of the body to excrete ingested water by increasing antidiuretic hormone levels and retaining sodium. When cardiac output and systemic blood pressure are reduced, "hypovolemic" hormones, such as renin (with a subsequent increase in angiotensin II formation), antidiuretic hormone (ADH), and norepinephrine, are released in an attempt to increase systemic blood pressure. Although heart failure patients have increased plasma and extracellular fluid volumes, the body perceives volume depletion (reduced effective arterial blood volume) since the low cardiac output decreases the pressure perfusing the baroreceptors in the carotid sinus and the renal afferent arteriole. This causes the kidneys to limit both sodium and water excretion in an attempt to return perfusion pressure to normal. ADH is released, which increases free water reabsorption in the collecting tubules. Angiotensin II and norepinephrine are also released, which limits water excretion by lowering the glomerular filtration rate (GFR). In addition, both the low cardiac output and high angiotensin II levels lead to increased thirst, causing increased water intake. The increase in aldosterone promotes sodium reabsorption, thus resulting in a urine sodium concentration of less than 20 mEq/L. In many cases, the increased free water intake and decreased GFR result in a hypervolemic hyponatremia as more water is retained (or more often, ingested) than sodium.

A grade II inversion ankle sprain presents with findings of moderate pain, ecchymosis, and swelling. The injury involves incomplete tearing of the anterior talofibular ligament and calcaneofibular ligament, which is appreciated with the mild joint instability, as noted with the anterior drawer test. The widening of the ankle mortise may not be apparent on your normal anteroposterior or mortise view x-ray. If the x-ray is normal and you have high suspicion, then the ankle should be placed into external rotation while the x-ray is being performed.

This patient has an ankle sprain, which is a common injury that involves stretching or partial or complete rupturing of ankle ligament(s). The most common mechanism of injury is plantarflexion and inversion at the subtalar joint, which affects the lateral ankle ligaments. The ligament most commonly injured is the anterior talofibular ligament (ATFL). The calcaneofibular ligament (CFL) is the next most commonly injured ligament with the posterior talofibular ligament rarely injured only with significant trauma. Ankle sprains are graded from I to III. A grade I sprain results from a mild stretch of a ligament with microscopic tears, a grade II sprain consists of an incomplete tear of ligaments, and a grade III sprain involves a complete tear of the ligament(s). Physical exam should include range of motion, assessment for swelling and ecchymosis; checking for point tenderness; and joint stability tests such as the anterior drawer test in plantarflexion (ATFL) and dorsiflexion (CFL), the talar tilt test (CFL), and the squeeze test. Anterior drawer test Performed with the foot in a neutral position. The lower leg is stabilized and the examiner applies anterior force to the posterior aspect of the foot It is positive if there is excessive anterior displacement indicating partial or complete tearing at the ATFL Talar tilt test Done with the foot initially in a neutral position It is then brought to inversion with the degree of inversion compared to the contralateral ankle The test is positive if there is increased laxity with inversion and indicates more complete ligamentous tears that extend through the ATFL and CFL and sometimes into the posterior talofibular ligament The squeeze test Performed by squeezing the fibula against the tibia at the mid-calf level The test is positive when there is a reproduction of pain at the anterior portion of the ankle, which indicates that a syndesmotic or high ankle sprain has occurred. The patient's presentation is consistent with a grade II inversion sprain with findings of moderate pain, ecchymosis, and swelling. The injury involves incomplete tearing of the ATFL and CFL, which is appreciated with the mild joint instability as noted with the anterior drawer test.Initial treatment for all ankle sprains consists of rest, ice, elevation, compression, nonsteroidal anti-inflammatory drugs, analgesics, and immobilization. Grade I and II sprains typically respond well to early mobilization and rehabilitation focused on ankle range of motion, ankle strengthening, and proprioceptive exercises. Grade III sprains often are treated with a short course of immobilization followed by early mobilization and rehabilitation focused on ankle range of motion, ankle strengthening, and proprioceptive exercises. In the case of elite athletes or high-demand patients and/or those failing conservative therapies, referral to an orthopedic surgeon for surgical intervention may be necessary.

Bottom Line: Patients with Turner syndrome often do not develop secondary sexual characteristics. They have a classic phenotypic appearance with short stature, lymphedema, and a shield chest. To confirm diagnosis of this condition, a karyotype should be completed.COMBANK Insight : Review the initial laboratory and diagnostic studies for the commonly tested syndromes, such as Turner syndrome. these patients are predisposed to osteoporosis due to the lack of estrogen the ovaries are making. These patients are treated with estrogen and progesterone to recreate the pubertal process. By giving the patient estrogen supplementation, the risk of osteoporosis and fracture drastically decrease. These patients should have a bone mineral density every 3 to 5 years to determine if any antiresorptive agents are needed to protect the bones. he lack of breast development is the most sensitive indicator that the ovaries have never secreted estradiol. Evaluation is indicated with the lack of any pubertal development by the age of 13 years, or the lack of menses with pubertal development by the age of 15 to 16. The typical sequence of puberty is growth acceleration, breast development, pubic hair development, maximum growth rate, menarche, and ovulation. After making the diagnosis of Turner syndrome, evaluation of thyroid function tests will be appropriate. Once the diagnosis is made, a baseline and then yearly thyroid function test and thyroid autoantibody screen is warranted. The incidence of autoimmune disorders is increased in these patients, with the most prevalent being autoimmune thyroiditis and Graves' disease, which occurs in 15% to 30% of patients. After the diagnosis of Turner syndrome is made, the patient will need a renal ultrasound, rather than a transvaginal ultrasound. A renal ultrasound is able to evaluate for renal anomalies, such as horseshoe kidney and malpositions.

This patient has classic features of Turner syndrome, which includes features such as lymphedema, short stature, exaggerated skin fold on the posterior neck, a broad shield-like chest, hypoplastic areolae, webbing of the neck, short metacarpals, low-set deformed ears, and scoliosis. Other medical concerns with Turner syndrome include cardiac and renal anomalies. These patients also have a higher incidence of diabetes, hypothyroidism, and hypertension. The ovaries in Turner syndrome are streak and lack oocytes and granulosa cells because of exaggerated oocyte atresia during fetal life. These patients will have high levels of follicle stimulation hormone and luteinizing hormone and low levels of estradiol. A karyotype must be done to make the diagnosis of this genetic condition. Approximately 60% of Turner cases are 45,X meaning they are missing the entire other X chromosome.In initial, osteopathic screening examination, observe the slope of the shoulder where it meets the neck. These 2 surfaces should be symmetric. They should meet the vertical muscle mass of the cervical spine in the mid-cervical region. Asymmetry must be interpreted in light of all the preceding data regarding scapular position. If a fold of skin attaches to the neck higher than the mid-cervical region, this constitutes a web neck, or pterygium colli. It may even attach as high as the mastoid process. This is associated with congenital disorders such as Klippel-Feil syndrome or Turner syndrome.

1. Obtain echocardiography 2. consult cardiology for consideration of left heart catheterization 3. Start carvedilol before discharge 4. Start lisinopril before discharge 5. Start IV furosemide Bottom Line: Adult patients presenting with heart failure should be evaluated with echocardiography and started on IV diuresis.

This patient has several risk factors for coronary artery disease (CAD) including diabetes, tobacco use, and advanced age. He has multiple signs and symptoms of heart failure which should be further evaluated with echocardiography. He describes New York Heart Association (NYHA) Class III symptoms and his examination is suggestive of a volume overload state. His EKG confirms a left bundle branch block (*auscultation revealed reverse splitting of S2). The management of new onset heart failure should include both diagnostic testing and medical management. Although there are several causes of heart failure, he has several risk factors for coronary artery disease (CAD). This warrants an ischemic evaluation especially if the patient's ejection fraction is reduced. Because he has a very high pretest probability of CAD, the most appropriate test for the evaluation of ischemia would be coronary angiography to see whether there are significant lesions.The mainstay of medical therapy for heart failure includes both beta blockers and ACE inhibitors (ACEi). This is true regardless of the cause of systolic dysfunction and even if the patient is asymptomatic (NYHA Class I). Beta blockers and ACEi have proven mortality benefit and should be started in all patients in the absence of contraindications. It should be noted that these medications are generally started after the patient is nearing euvolemia and is getting ready for discharge and not when the patient initially presents to the hospital. This patient is volume overloaded and should be started on IV diuretics immediately for symptom relief.

Bottom Line: Bacterial vaginosis is characterized by a gray discharge that has a fishy odor with an alkaline pH and clue cells as seen on microscopy.

True Bacterial vaginosis is one of the most common causes of vaginitis in premenopausal women, accounting for 40% to 50% of the causes of vulvovaginitis. This occurs secondarily to a change in the vaginal ecosystem. It is not sexually acquired. Clinical diagnosis requires a speculum examination of the vaginal discharge and a microscopic evaluation of the discharge, which is called a wet prep. Findings indicative of this diagnosis include a thin, gray homogeneous discharge, a pH greater than 4.5, a fishy odor, and the presence of clue cells. In order to make the diagnosis there must be at least 3 of the above-listed items. The microscopic photograph is of clue cells.

characteristic high anion gap acidosis greater than 16 mEq/L. Remember, the formula to calculate the anion gap is Na+ − (Cl− + HCO3−) INDICATES

This patient is presenting with acute alcoholic ketoacidosis. This is a condition seen after heavy alcohol consumption along with decreased or absent food intake for several days. The combination of decreased insulin secretion, increased glucagon secretion, and ethanol-induced inhibition of glyconeogenesis results in lipolysis. Ketones including acetoacetate, hydroxybutyrate, and acetone accumulate, which causes the symptoms of nausea, vomiting, and abdominal pain. The hallmark of alcoholic ketoacidosis is a characteristic high anion gap acidosis greater than 16 mEq/L. Remember, the formula to calculate the anion gap is Na+ − (Cl− + HCO3−). Blood alcohol levels are usually low or not detectable. A normal glucose is what distinguishes alcoholic ketoacidosis from a diabetic ketoacidosis. Other electrolyte abnormalities that can be seen are hypokalemia, hyponatremia, and hypophosphatemia. This patient has a high anion gap acidosis (133 - 95 - 10 = 28) with a normal glucose. Intravenous fluids and glucose administration are the mainstay of therapy. Thiamine can be administered but should be given prior to the administration of glucose to prevent acute onset of Wernicke encephalopathy. Insulin is not indicated and can cause hypoglycemia. A normal glucose is what distinguishes alcoholic ketoacidosis from a diabetic ketoacidosis.

diffuse cutaneous systemic sclerosis (dcSSc).

This patient is presenting with the signs and symptoms of diffuse cutaneous systemic sclerosis (dcSSc). They have bilateral lung infiltrates with chronic cough and shortness of breath which is concerning for interstitial lung disease, a loud P2 on exam which is concerning for the development of pulmonary hypertension, significant systemic hypertension which is concerning for renal-vascular disease and scleroderma renal crisis, as well as GERD, Raynaud's phenomena, and signs of cutaneous sclerosis with significant skin involvement beyond the hands. Scleroderma is a subset of the autoimmune disease known as systemic sclerosis (SSc). Scleroderma is generally considered to be the subset of SSc known as diffuse cutaneous or dcSSc. CREST syndrome is considered to fall under the category of limited cutaneus or lcSSc. The exact etiology of SSc is unknown. It is characterized by induration and thickening of the skin, along with varying degrees of soft tissue fibrosis. Chronic inflammatory changes are commonly seen and can affect any organ system, though the renal, pulmonary, and gastrointestinal systems are common. Presenting symptoms include hypopigmentation of skin, Raynaud phenomenon, gastroesophageal reflux due to lower esophageal sphincter incompetence, calcinosis cutis, hyperpigmentation, and mucocutaneous telangiectasia, as well as systemic hypertension, renal failure, pulmonary hypertension, interstitial lung disease, and intestinal dysmotility. Scleroderma is a systemic autoimmune disorder that affects multiple organ systems and can be localized such as with CREST or diffuse.

Bottom Line: Colorectal cancers in Lynch syndrome differ from sporadic colorectal cancers in that they are predominantly right-sided in location. The Amsterdam criteria can be remembered by the "3-2-1 rule" (3 affected members, 2 generations, 1 under age 50). These patients can be sent for genetic testing. Due to increased emphasis on screening practices, colon cancer is now often detected during screening procedures. Other common clinical presentations include iron deficiency anemia, rectal bleeding, abdominal pain, change in bowel habits, and intestinal obstruction or perforation.

This patient presentation is most consistent with hereditary nonpolyposis colon cancer (HNPCC), also known as Lynch syndrome. Lynch syndrome is an autosomal dominant disorder that is caused by a germline mutation in one of several DNA mismatch repair genes or loss of expression of MSH2 due to deletion in the EPCAM gene. It is the most common inherited colorectal cancer susceptibility syndrome.According to the Amsterdam II criteria, Lynch syndrome should be suspected in patients who meet all of the following criteria:1. Three or more relatives with Lynch syndrome-associated cancers that were histologically verified (colorectal cancer, cancer of the endometrium or small bowel, transitional cell carcinoma of the ureter or renal pelvis), 1 of whom is a first-degree relative of the other 2 and in whom familial adenomatous polyposis (FAP) has been excluded.2. Lynch syndrome-associated cancers involving at least 2 generations.3. One or more cancers were diagnosed before the age of 50 years.The Amsterdam criteria can be remembered by the "3-2-1 rule" (3 affected members, 2 generations, 1 under age 50). Colorectal cancers in Lynch syndrome differ from sporadic colorectal cancers in that they are predominantly right-sided in location. Patients meeting Amsterdam II criteria can be considered for genetic testing.

----- a fungal infection caused by Pityrosporum orbiculare or ovale. It causes annular hypopigmented scaly macules, which usually appear on the chest and back. It is common in young adults and teenagers due to increased sebaceous gland activity. A diagnosis can be made by the appearance of the classic "spaghetti and meatballs" on KOH prep. Initial treatment of choice is topical ketoconazole 2% or selenium sulfide 2.5% suspension. Oral antifungals may be used in resistant or recurrent cases.

Tinea versicolor is a fungal infection caused by Pityrosporum orbiculare or ovale. It causes annular hypopigmented scaly macules, which usually appear on the chest and back. It is common in young adults and teenagers due to increased sebaceous gland activity. A diagnosis can be made by the appearance of the classic "spaghetti and meatballs" on KOH prep. Initial treatment of choice is topical ketoconazole 2% or selenium sulfide 2.5% suspension. Oral antifungals may be used in resistant or recurrent cases.

Necrobiosis lipoidica

Treatment for necrobiosis lipoidica is not very effective, partially because the exact etiology remains unknown. Because localized trauma can cause necrobiosis lipoidica to ulcerate, protection of the legs with elastic support stockings and leg rest may be helpful.Necrobiosis lipoidica Necrobiosis lipoidica is a disorder of collagen degeneration with a granulomatous response, thickening of blood vessel walls, and fat deposition. is a vasculitis, which occurs primarily in diabetics and produces a well-demarcated area of atrophy that gradually enlarges. These lesions primarily occur on the shin, and can be differentiated from others, because they are often painless due to diabetic neuropathy. Patients usually present with shiny, asymptomatic patches that slowly enlarge over months to years. The patches are initially red-brown and progress to yellow, depressed, atrophic plaques. Ulcerations can occur, typically after trauma and occasionally with associated pain. The patient's main complaint is the unsightly cosmetic appearance of the lesions.

----presents with vaginal and cervical inflammation. Cervical petechiae/strawberry color is present. Malodorous, frothy, greenish, copious discharge may also be present and the pH is > 4.5. Diagnosis is made with a saline wet mount which will show flagellated motile organisms. Treatment is metronidazole. The partner should also be treated though men are typically asymptomatic.

Trichomonas

At 6 months of age, a child can sit unassisted, babble, and transfer objects; has a raking grasp; and experiences stranger anxiety.

True

Bottom Line: Any patient with a newly diagnosed PE or DVT and good renal function and no contraindications should be started on a factor Xa inhibitor.

True

Bottom Line: Down syndrome complications include duodenal atresia and early Alzheimer's disease. Patients with duodenal atresia present with bilious vomiting and abdominal distension within the first two weeks of life and an abdominal x-ray will reveal the classic double-bubble sign.

True

Bottom Line: Eosinophiluria, eosinophilia, low-grade fevers, mild proteinuria, and arthralgias, in the setting of exposure to medication, should raise your suspicion for acute interstitial nephritis (AIN). The most important treatment is to stop the offending agent.

True

Bottom Line: Leriche syndrome is a subtype of peripheral artery disease that involves pathology of the aortoiliac arterial system.

True

Bottom Line: Yawning and piloerection are very specific for opioid withdrawal. Other symptoms include dilated pupils (mydriasis) and diarrhea due to increased GI motility. COMBANK Insight :The symptoms of a drug's withdrawal syndrome are usually the opposite of the intoxication syndrome. For example, morphine causes constipation. In withdrawal you commonly see severe diarrhea.

True

Buspirone is a nonbenzodiazepine antianxiety agent used as a long-term maintenance therapy for patients suffering from generalized anxiety disorder and would serve no benefit for the above patient.

True

CREST has a better prognosis than scleroderma. Treatment includes methotrexate and cyclophosphamide. Patients with renal involvement should be treated with an ACE inhibitor and hydration.

True

Cystoscopy is useful in the evaluation and work-up of hematuria, but is not indicated in this patient as the urinalysis was negative for presence of red blood cells.

True

Decreased pulses in the affected leg of a patient with calf pain would be consistent with peripheral vascular disease. Patients have claudication, or pain in legs especially with activity from vascular occlusion. Examination may also reveal a cold limb, poorly healing ulcers, or diminished hair and nail growth on affected side.

True

Dermatomyositis and polymyositis both have ANA and Anti-Jo-1 antibodies as their immunologic markers. Be sure to be able to distinguish between them. Laboratory testing, in patients with dermatomyositis, will reveal elevated creatinine kinase and aldolase enzymes.

True

Due to the fact that the patient is immunocompromised secondary to therapy for leukemia, and the rash appears vesicular in a cranial nerve V1 distribution, the most likely cause is a varicella zoster virus eruption. The eye is most likely involved when the tip of the nose or nares are involved. This is known as Hutchinson sign, which is due to involvement of the nasociliary branch of cranial nerve V1.

True

Relative contraindications to HVLA include patients who are pregnant, have recently experienced whiplash injury, have history of vertebral artery ischemia, and patients on anticoagulation.

True

Screening for colon cancer should begin at age 50, if there is no family history, and if the patient is asymptomatic. However, if there is a positive family history, screening should begin at age 40, or 10 years earlier than the age the youngest family member was when he or she was diagnosed with cancer (whichever is earlier).

True

The 3 cancers with the highest mortality rate in women, in decreasing order, are lung > breast > colorectal. Substituting breast for prostate, the list is the same for men: lung > prostate > colorectal.

True

Thickened palpable veins or cords can be seen in patients who have superficial thrombophlebitis. Treatment is supportive with non-steroidal inflammatory medications for pain relief.

True

he positive leukocyte esterase is highly sensitive and specific for urinary tract infection and the positive nitrite test indicates the presence of nitrate-reducing organisms. Nitrofurantoin is an appropriate first-line antibiotic choice for uncomplicated UTI as it becomes highly concentrated within the urinary tract. This patient has no fevers and a normal WBC count which is reassuring that this is not likely pyelonephritis, despite the flank pain which has been going on for 3 weeks now and is likely unrelated. Other possible options would include the use of TMP-SMX, ciprofloxacin, fosfomycin, or cephalexin. Fosfomycin can be given in a single dose, while three days of therapy with other drugs is generally sufficient for uncomplicated UTIs. Of note, cephalexin has a generally broader spectrum and has higher rates of vulvovaginal candidiasis associated with its use. Across the USA, many strains of E. coli. have become resistant to TMP-SMX and/or ciprofloxacin. In communities with high rates of ciprofloxacin resistance, TMP-SMX is the preferred drug. If there is known resistance to both drugs, then an alternative drug should be chosen. You could also provide the patient with acetaminophen for fever and/or pain control, though few insurance companies will cover over-the-counter medications and the cost to the patient will likely be the same. Phenazopyridine (Pyridium) is also helpful as an analgesic, but warn your patient that it will turn their urine bright orange. There is no evidence that cranberry juice helps cystitis and no evidence has shown that drinking more water assists in bacterial clearance. In fact, some experts will note that drinking increased fluids may result in decreasing urinary concentrations of antibacterial substances such as Tamm-Horsfall protein which may be inadvertently detrimental to the resolution of the infection.

Uncomplicated cystitis can be treated with oral antibiotics that cover the most common causes of urinary tract infections. Nitrofurantoin is concentrated in the urine, making it an excellent choice for uncomplicated UTI, but a poor choice for pyelonephritis as it does not get adequate tissue penetration. Other options would include ciprofloxacin, cephalexin, TMP-SMX, and fosfomycin. piperacillin- tazobactam (Zosyn) is an IV antibiotic with broad spectrum coverage, which is not indicated for the treatment of uncomplicated UTI. This patient has no signs of a complicated urinary tract infection despite complaining of some mild flank pain. There is no fever, tachycardia, or objective signs of pyelonephritis.

This patient's laboratory workup shows multiple abnormalities consistent with chronic lymphocytic leukemia or CLL and autoimmune hemolytic anemia (AIHA). First, on the blood count, there is an absolute increase in white blood cells with a predominance of lymphocytes. There is also anemia and thrombocytopenia which are consistent with likely hemolytic anemia and possible immune thrombocytopenia from underlying malignancy. Patients with CLL have a 5-10% risk of developing autoimmune complications, the most common of which is a hemolytic anemia. They can also develop immune thrombocytopenia and autoimmune granulocytopenias. The appropriate management for suspected AIHA is to obtain a direct coombs test or DAT. This tests for antibodies or the fixation of complement on the surface of red blood cells by mixing the patient's red blood cells with rabbit or mouse antibodies against human IgG or C3. Agglutination means that the cells have been cross-linked by the added Ig and represents a positive test. The coating of patient RBCs by antibody results in the characteristic spherocytes seen on peripheral smear. As these cells pass through the spleen, they are partially digested by macrophages, reducing the cell surface area and altering the red cell morphology from disks to spheres. AIHA can be due to both warm or cold agglutinin disease which refers to the temperature at which cells agglutinate. Warm AIAH is generally due to IgG while cold disease is generally due to IgM. In either case, the finding of AIHA should raise concern for some kind of underlying process. While it can be idiopathic, it is commonly associated with lymphoproliferative disorders such as CLL or non-Hodgkin's lymphoma. Causes of hemolytic anemia are listed in the table below.

True

Todd paralysis is believed to happen because of depressed activity in the area of the person's brain where the seizure activity occurred. The symptoms of Todd paralysis depend upon the area of the person's brain where the seizure occurred. For example, if the seizure happened in the person's motor cortex, Todd paralysis can result in hemiparesis. Occipital lobe seizures might result in visual changes or even blindness during the postictal period. The symptoms of Todd paralysis often disappear within minutes to hours of their initial onset. On rare occasions, the symptoms can last for 36-48 hours. Eventually the symptoms of Todd paralysis disappear, and the person's functionality returns.

True

Wilson disease results in inappropriate deposition of copper in the liver, brain, and other tissues. It is an autosomal recessive disease affecting chromosome 13. Signs and symptoms are the consequence of cirrhosis, basal ganglia deterioration, and deposition of copper in other tissues, causing hepatic failure, neurologic abnormalities, hemolytic anemia, and Kayser-Fleischer rings around the iris. Basic labs will reveal hemolytic anemia (decreased hemoglobin and hematocrit with elevated bilirubin as well as decreased haptoglobin and increased reticulocyte count) and elevated liver enzymes due to cirrhosis. Decreased ceruloplasmin (less than 20 mg/dL) is diagnostic of Wilson disease in patients presenting with neurologic symptoms and Kayser-Fleischer rings.

True

Lead toxicity is a major concern in children presenting with neurological symptoms as well as microcytic anemia and vomiting. Neurotoxicity in children can occur with blood lead levels as low as 10 ug/dL. These effects can be long-standing and can possibly be permanent. The presence of cerebral edema is a poor prognostic indicator. Treatment of suspected lead toxicity includes oral chelation with succimer or parenteral chelation with dimercaprol or EDTA.

True Bottom Line: Lead toxicity should be ruled out in a child presenting with altered mental status, seizure activity, and microcytic anemia.COMBANK Insight : Pediatric toxicology is a very high yield subject. Try to learn how each toxin presents and the antidote.

Bupropion has been approved for both the treatment of refractory depression and smoking cessation. It is thought to block the reuptake of norepinephrine and dopamine. It has been shown to lower the seizure threshold, and its use should be avoided in patients with a history of seizure activity or eating disorders.

True Bupropion is contraindicated in patients with a history of seizures. Common side effects of bupropion therapy include the following: insomnia, seizures, sweating, weight loss, and decreased appetite.

Changes in abdominal shape may be associated with a uterine rupture, which usually occurs with trauma or a uterine scar. The abdomen may change shape in uterine rupture because the fetus is no longer contained within the uterus.

True Changes in abdominal shape may be associated with a uterine rupture, which usually occurs with trauma or a uterine scar.

Bottom Line: Medical care consists of establishing the diagnosis and reason for the iron deficiency. In most patients, the iron deficiency should be treated with oral iron therapy, and the underlying etiology should be corrected so the deficiency does not recur. However, avoid giving iron to patients who have a microcytic iron-overloading disorder (e.g. thalassemia, sideroblastic anemia). Do not administer parenteral iron therapy to patients who should be treated with oral iron, as anaphylaxis may result.

True Ferritin is a storage protein for iron. If the patient is iron deficient, they will have low iron stores and low ferritin.

Bone is the least radiosensitive tissue in the body.

True Ionizing radiation can be produced in many settings. Two common examples seen in a clinical setting include x-rays and gamma rays. The pathophysiology and the effects of ionizing radiation correlate with the type of radiation, cumulative dose, and the amount of body surface area exposed. Radiation can cause direct or indirect DNA injury through the formation of hydroxyl free radicals. The most radiosensitive tissues are those with the highest mitotic activity. Lymphoid tissue is most susceptible to the effects of radiation followed by bone marrow, gastrointestinal mucosa, and germinal tissue. The least radiosensitive tissues are bone, followed by brain, muscle, and skin. Radiation affects different tissues in different ways. It can affect the hematopoietic system, leading to lymphopenia, thrombocytopenia, and bone marrow hypoplasia. It can cause vascular thrombosis and fibrosis. In the epidermis, it can cause erythema, edema, and blistering. Radiation can also cause cancers such as acute leukemia, papillary carcinoma of the thyroid, and osteogenic sarcoma.

Bottom Line: Myasthenia gravis is a contraindication to administering magnesium sulfate.

True Myasthenia gravis is a contraindication to giving a patient magnesium sulfate. Myasthenia gravis is an autoimmune disorder that leads to fluctuating muscle weakness and fatigue. These patients have circulating antibodies that block acetylcholine receptors. Magnesium sulfate works by allowing magnesium to compete with calcium channels. Therefore, this medication will have deleterious effects on neuromuscular transmission.

relative contraindications to lymphatic treatments: Osseous fractures Bacterial infections with a temperature >102F Abscess or localized infection Certain stages of carcinoma true or false?

True Post streptococcal glomerulonephritis is a type of nephritic syndrome that may occur one to three weeks following an infectious process, most typically Group A Beta hemolytic streptococci. It usually affects children with a history of strep throat or upper respiratory infection 1 to 3 weeks prior. Nephritic syndrome presents with hypertension, edema, hematuria, oliguria, azotemia, and proteinuria. In post streptococcal glomerulonephritis, IgG and C3 deposits will be present on biopsy in a granular patter, elevated antistreptolysin titer and a decreased C3 serum level. Electron microscopy will reveal a lumpy bumpy appearance caused by subepithelial immune complex deposition. Treatment is supportive. Osteopathic Pearl: The patient's leg swelling can be treated with osteopathic lymphatic treatments. The lymphatic treatments can be divided into two categories; those that improve restrictions, and those that augment lymphatic flow. Treatment protocols should include techniques from both categories. First, start with techniques that improve restriction, then apply techniques that augment flow. A basic sequence for a lymphatic treatment program should include: Treat any thoracic inlet somatic dysfunction Rib raising or paraspinal inhibition to improve respiration and normalize hypersympathetic activity Redome the thoracoabdominal diaphragm to maximize lymph return Apply lymphatic pump techniques to return lymph through open channels

A short course of low-dose steroids can reduce morbidity and mortality associated with prematurity, specifically with the reduction of respiratory distress, intraventricular hemorrhage, and necrotizing enterocolitis.

True Studies have proven the effectiveness of steroid use in pregnancy to reduce the risk of diseases of prematurity. Steroids have been shown to decrease the incidence of respiratory distress syndrome, intraventricular hemorrhage, and necrotizing enterocolitis in premature infants. The course of steroids is given over a 24-hour time frame. Steroid effect is greatest at about 7 days. The most common steroids administered for this purpose are betamethasone or dexamethasone. These steroids are the smallest compounds that are able to cross the placenta and reach the fetus. Ideally, steroids are given to patients with a high risk of premature delivery from 24 to 34 weeks of gestation, although some experts endorse steroid use up to 36 weeks. The patient in this scenario is a good candidate for steroid use to reduce the risk of diseases of prematurity.

Before surgical intervention for appendicitis, patients should be resuscitated with fluid if necessary, started on antibiotics that cover gram-negative organisms and enteric bacteria, and have adequate IV access and pain control.

True The patient should have 1 or preferably 2 peripheral IV lines before being transferred to the operating room.The patient is tachycardic and has an elevated lactate and high WBC count with suspected appendicitis. Therefore, this patient has sepsis by definition and should be resuscitated with fluids before the initiation of vasopressors or the placement of invasive lines. She will also be NPO for surgery; giving an IV fluid bolus followed by maintenance is appropriate.The patient should be medicated for pain or discomfort. Morphine is generally a good first-line pain medication in a patient with severe pain. Morphine is dosed by body weight in the acute setting and can be safely administered at a dose of 0.1 mg/kg body weight with redosing of 0.025 to 0.05 mg/kg every 5 minutes until adequate analgesia is achieved.Antibiotics should be given for acute appendicitis, even if there is no perforation noted on CT scan, because studies have shown improved outcomes with 24 hours of antibiotics. If there was concern for perforation, up to 5 days of therapy would be necessary postoperatively. Antibiotics that cover for intestinal flora are generally acceptable, such as penicillins/cephalosporins. If the beta-lactam antibiotic chosen does not have good anaerobic coverage, then metronidazole should be added. Cefoxitin is a second-generation cephalosporin and has sufficient coverage to be used as monotherapy.

Treatment of zoster includes the use of antivirals to help quicken the healing of the lesions, decrease the duration and severity of acute neuritis, and to decrease viral sheading. Treatment should ideally be initiated within 72 hours. Common antiviral medications are acyclovir, valacyclovir, and famciclovir. If the patient's zoster involves the V1 branch, as with the patient above, the patient should be referred to an ophthalmologist to ensure the health of the cornea.

True This patient is presenting with varicella-zoster virus (VZV), also known as shingles, involving the trigeminal nerve of the face. Varicella-zoster lesions on the tip of the nose are known as Hutchinson signs. There is a crossover with innervation to the cornea via the nasociliary branch of the V1 trigeminal nerve. If the tip of the nose or the region inside the nares is involved in VZV, the cornea should be evaluated with fluorescein for pseudodendrites.

The goal of treatment in the setting of hemochromatosis is to lower total body iron levels in an effort to prevent worsening organ failure secondary to iron deposition. Although both phlebotomy and deferoximine may be used to decrease iron stores in patients with suspected hemochromatosis, initiating therapy with weekly phlebotomy is both cost efficient and effective. In patients without anemia and signs of iron overload, phlebotomy is preferred, as it is easy, cheap, and without significant side effects. Phlebotomy should be performed weekly until ferritin levels fall to 50 to 100 μg/L. At this time, maintenance phlebotomy can be performed every 2 to 4 months with or without deferoxamine.The indications for phlebotomy include: Serum ferritin ≥1000 ng/mL (≥2247 pmol/L) and often ≥500 ng/mL (≥1124 pmol/L) Tissue injury due to iron overload such as transaminitis or cardiac dysfunction Increased tissue iron seen on MRI or other study or pathology Phlebotomy should not be used in asymptomatic individuals, even with known hemochromatosis, if serum ferritin is not ≥500 ng/mL (≥1124 pmol/L) and there are no signs of iron deposition. There is some evidence that phlebotomy may improve hepatic fibrosis, cardiomyopathy, and hypogonadism. It is not known to improve diabetes or arthritis.

True Weekly phlebotomy is the best initial therapy for acute, symptomatic hemochromatosis with signs of end-organ damage secondary to iron overload.

Hypertension is a risk factor for placenta abruption which presents with painful bleeding, contractions, and fetal distress. It is an emergency that requires immediate c-section. true or false

True -Cocaine abuse is another risk factor for placenta abruption which presents with painful bleeding, contractions, and fetal distress.

------ has been shown to slow the progression of the primary biliary cirrhosis.

Ursodeoxycholic acid

Bottom Line: DVT classically produces pain and limb edema, which is the most specific symptom of DVT.

True DVT is the presence of a thrombus in one of the deep venous conduits that return blood to the heart. The clinical conundrum is that symptoms (pain and swelling) are often nonspecific or absent. However, if left untreated, the thrombus may become fragmented or dislodged and migrate to obstruct the arterial supply to the lung, causing potentially life-threatening pulmonary embolus. Physical exam findings, though not always present, include calf edema, erythema, warmth to touch, and calf tenderness to palpation. Some percentage of venous thrombosis will present with slight increases in patient temperature or actual clinical fever. In patients who are hospitalized for fever of undetermined origin, venous thrombosis is generally considered as a possible option for underlying cause. Fever as defined by IDSA is greater than 38C sustained or 100.4 F. In a patient's history, look for long periods of leg immobilization (causing venous stasis) such as a recent lower extremity surgery, injury leading to prolonged bed rest, leg in a cast, long flights, etc

Painful vaginal bleeding is placental abruption until proven otherwise. Painless vaginal bleeding is generally considered to be placenta previa until proven otherwise.

True Given the presentation of acute onset vaginal bleeding and severe abdominal pain with contractions, this patient is most likely suffering from placental abruption. This is a condition in which the placenta shears away from the uterine wall often due to trauma or mechanical event, but can also happen spontaneously. The diagnosis is made clinically. Most patients were present with some combination of abdominal pain or back pain (if the placenta is on the posterior uterine wall), may have contractions, and may and may not have vaginal bleeding, which can be clinically significant with hypotension and shock or quite minor. The presentation is quite variable. The amount of vaginal bleeding itself does not correlate with maternal or fetal risk, as significant bleeding can be hidden between the uterus and the placenta. Signs that do correlate with the severity of placental abruption include significant abdominal pain, hemodynamic compromise, and significant fetal heart rate abnormalities. Fetal compromise and disseminated intravascular coagulation (DIC) are much more likely when placental separation exceed 50%. 10-20% of placental abruption is present only with pre term labor, as the hemorrhage is contained between the placenta in the uterus, and only found on ultrasound. Even scant bleeding in the setting of preterm labor should prompt a search for placental abruption.

Bottom Line: Amaurosis fugax refers to transient monocular blindness, generally involving carotid emboli, with occlusion of the ophthalmic artery.

True Individuals often describe the event as if "a shade or curtain was pulled over my eye." The event itself is short-lived but may be a harbinger to a more severe cerebrovascular territory infarction and should be evaluated as such. The risk of stroke increases by approximately 2-3% per year after monocular vision loss secondary to carotid disease. Blindness itself is often caused by an embolus, most commonly originating in the carotid artery, which ultimately occludes the ophthalmic artery. Evaluation should begin with an appropriate history and physical with ocular, cardiac, neurological, and carotid exams. Atherosclerosis of the carotid arteries is the overall number one cause of amaurosis fugax due to showering of tiny emboli into the retinal artery.

Permethrin cream should not be applied to the face. It should be applied only from the neck down on a patient with scabies?

True Scabies infection is a disease occurring via direct skin-to-skin contact and usually causes an intensely pruritic, excoriated papular rash on the genitalia, axillae, and hands. The pruritus is worse at night. Treatment is with 5% permethrin applied overnight from the neck down and repeated in 7 to 10 days with treatment of close contacts.

----presents with multiple skin abnormalities, in addition to central nervous system involvement (often seizure disorder) and potential other organ involvement. The skin findings associated with TS include the shagreen patch (collegenoma), adenoma sebaceum (facial angiofibromas), ash leaf spot, and periungual fibroma.

Tuberous Sclerosis TS, also known as Bourneville's disease and epiloia, is an uncommon genetic disorder that affects the skin, central nervous system, and other organs. It has an equal male-to-female incidence and typically presents at or shortly after birth. There are several skin findings associated with TS, including the shagreen patch, a connective tissue nevus or collagenoma that typically appears as a white-to-yellow plaque with a pebbled surface on the lumbosacral area. The earliest sign of TS is often the ash leaf sign, shown here, which presents as a hypopigmented macule or patch on the trunk or extremity that is accentuated with a Wood's lamp examination. Other skin manifestations that are common in TS include periungual fibromas (also known as Koenen's tumor) and adenoma sebaceum (facial angiofibromas). Patients with TS may also have a seizure disorder if the central nervous system is affected. In addition, these patients may have other features, such as retinal hamartomas, angiomyolipomas, cardiac rhabdomyoma, and pulmonary cysts. Management includes complete physical examination with imaging studies and referral to a pediatric neurologist. Patients with suspected tuberous sclerosis should have an MRI of the brain done to look for calcified nodules as they may progress to gliomas.

Ulcers in the mucous membranes of the mouth and nose are a complication of late mucocutaneous leishmaniasis, transmitted by the ----

Ulcers in the mucous membranes of the mouth and nose are a complication of late mucocutaneous leishmaniasis, transmitted by the sandfly.

Bottom Line: ------is the most common cause of postpartum hemorrhage.

Uterine atony The leading cause of postpartum hemorrhage is uterine atony, and thus, given the current information in this stem, this is the most likely current cause of her bleeding given no other information. Other less common causes include trauma due to lacerations, uterine rupture, surgical incision bleeding, and coagulopathy. Coagulopathy during pregnancy or delivery may be associated with HELLP syndrome (hemolysis, elevated liver enzymes, low platelets), amniotic fluid embolism, placental abruption, or preeclampsia. The definition of postpartum hemorrhage was revised in 2017 by the American College of Obstetricians and Gynecologists as either:1. Cumulative blood loss ≥1000 mL, or2. Bleeding associated with signs and/or symptoms of hypovolemia within 24 hours of the birth process, regardless of delivery route (vaginal delivery or cesarean section)The patient's tachycardia and lightheadedness are concerning early signs of hypovolemia due to blood loss. There are several factors that place patients at risk for this condition. These include the following: history of chorioamnionitis, magnesium sulfate exposure, macrosomia of the fetus, prior history of atony, multiple gestations, and multiparity. The patient above has several of these risk factors, placing her at an increased risk for uterine atony.

------ are rare and should be considered in patients with watery diarrhea when there is absence of pain, travel, recent antibiotic use, or any other more common cause. These tumors are highly malignant, and approximately 60%-80% have metastasized by time of diagnosis. Other key clinical features include flushing, hypokalemia, low serum chloride, lethargy, and muscle cramps.

VIPomas A VIPoma is a rare neuroendocrine tumor, typically of the pancreas, with high malignant potential. The tumor secretes vasoactive intestinal peptide (VIP). A clinical syndrome can be seen, which consists of watery diarrhea, hypokalemia, acidosis, facial flushing, hypochlorhydria, and hypercalcemia. It is more common in males between the ages of 30-50. Elevated VIP levels are diagnostic.

----- is a conditioned reflex related to contraction of the muscles of the pelvic floor, preventing vaginal penetration. It is commonly seen in patients with a history of sexual abuse, those who are taught that sex is immoral or vulgar, or individuals with a painful first-encounter sexual experience.

Vaginismus

----- intoxication produces a unique syndrome consisting of hypernatremia, metabolic acidosis, hypocalcemia, elevated serum ammonia, and mild liver aminotransferase elevation.

Valproic acid This patient most likely is intoxicated with valproic acid. This drug is widely used in the management of seizure and mood disorders. Valproic acid intoxication produces a unique syndrome consisting of hypernatremia, metabolic acidosis, hypocalcemia, elevated serum ammonia, and mild liver aminotransferase elevation. Hypoglycemia may occur as a result of hepatic metabolic dysfunction. Coma with small pupils may be seen, and this can mimic opioid poisoning. Encephalopathy and cerebral edema can occur.

------- for patients with infective endocarditis is indicated for the following: prosthetic valve endocarditis, uncontrolled infection, suppurative local complications with conduction abnormalities, ineffective antimicrobial therapy, repeated systemic embolization, and refractory congestive heart failure.

Valve replacement surgery

constant aching pain in his scrotum present on and off since puberty, short-lived but noticed steady progression in the size of his scrotum and pain severity. pain is worse on the left side without radiation. physical exam shows left sided scrotal mass that does not transilluminate and normal sized testicles. Size of the mass and associated pain increase with bearing down and decrease with lying recumbent. Osteopathic examination reveals a left-sided tender, body tissue texture abnormality overlying the T10-T11 musculature. what is the most likely diagnosis? A. Epididymitis B. Hydrocele C. Testicular cancer D. Testicular torsion E. Varicocele

Varicocele A varicocele is due to dilation of the paminiform venous plexus. it is classically described as a "bag of worms" It can be asymptomatic or present with a vague aching scrotal pain. It affects the left testicle more than the right because the left renal vein is compressed between the aorta and the superior mesenteric artery. The left testicular vein drains into the left renal vein, whereas the right testicular vein drains into the inferior vena cava. A varicocele may disappear in the supine position and does not transilluminate on physical exam. Ultrasound can be helpful for diagnosis. If symptomatic or if the testes makes up less than 40% of total scrotal volume, it may be treated surgically with a varicocelectomy, ligation, or embolization via interventional radiology. Viscerosomatic reflexes are a type of somatic dysfunction caused by changes in the autonomic nervous system. They can be acute or chronic and are considered to be a somatic representation of visceral disease. When either branch of the autonomic nervous system (sympathetic or parasympathetic) overstimulates a particular organ, a reflex reaction occurs. The soma at the same level of the organ's autonomic innervation takes on characteristics of somatic dysfunction (TART). T10-T11 is where the sympathetic viscerosomatic reflex for the testes is located. (Remember that the parasympathetic viscerosomatic reflex for the testes is carried via cranial nerve X.) Acute and chronic somatic dysfunction findings differ in tissue texture changes, restriction, and tenderness. In patients with chronic somatic dysfunction, the tissue texture changes are cool, dry, flaccid, ropy, and fibrotic. The restriction is present, but there is decreased or no pain. Tenderness in chronic somatic dysfunction is described as dull, achy, and burning.

--------is a common diagnosis and is usually self-limiting. Diarrhea is the most common presenting symptom, although nausea and vomiting may also be noted.

Viral gastroenteritis

Hydroxycobalamin (vitamin B12) deficiency can result from decreased production of intrinsic factor in the stomach, or absorption of the B12 and intrinsic factor complex in the ileum. The history states that this patient had multiple bowel resections, likely resulting in a deficiency of this vitamin. Vitamin B12 is one component essential to DNA synthesis. It is required for maintenance and formation of nerve sheaths, red blood cells, proteins, and folate and homocysteine recycling. Vitamin B12 can be stored in the liver for extended periods of time. Deficiency can lead to a nutritional optic neuropathy that results in a painless, progressive vision loss. Color desaturation may be present, as well as central or cecocentral scotomas. Other classical findings of B12 deficiency include ataxia, cognitive disturbances, peripheral sensory deficits, and weakness. Macrocytic anemia is a common lab finding.

Vitamin deficiencies and toxicities, including vitamin B12 deficiency, may cause optic neuropathies resulting in decreased vision and color perception changes.

------- is a clonal disorder of B cells that leads to a monoclonal gammopathy which can result in a hyperviscosity syndrome.

Waldenstrom's macroglobulinemia Of the options presented, the most likely diagnosis is Waldenstrom's macroglobulinemia (WM). WM is a clonal disorder of B cells that leads to a monoclonal gammopathy which can result in multiple complications, including hyperviscosity syndrome. Elevated levels of IgM may cause coagulation abnormalities, cryoglobulinemia, and amyloidosis. Patients often present with lethargy, weight loss, Raynaud's phenomenon and neurologic complaints such as peripheral neuropathy, blurry vision, or headaches which may be secondary to a hyperviscosity syndrome. Organ dysfunction affecting the skin, GI tract, kidneys, heart, and lungs may be seen. As is the case in multiple myeloma, MGUS is a precursor of WM. Labs may show an elevated ESR, uric acid, LDH, signs of kidney failure and increased alkaline phosphatase. A bone marrow biopsy and aspirate are required to establish the diagnosis and help differentiate it from multiple myeloma. Dutcher bodies are PAS staining IgM deposits around the nucleus and may be seen within plasma cells of marrow aspirates. Waldenstrom macroglobulinemia is a clonal disorder of B cells that leads to a monoclonal gammopathy, which can result in a hyperviscosity syndrome that is best treated acutely with plasmapheresis.

Disseminated intravascular coagulopathy (DIC) is defined by activation of the coagulation cascade, fibrin deposition within the microvasculature, fibrinolysis, hemolysis, thrombocytopenia, and consumption of all of the clotting factors. There are many different risk factors for DIC, and these include the following: massive tissue injury extensive vascular endothelial injury shock ABO transfusion incompatibility amniotic or fat embolism burns traumatic brain injury cancer severe or systemic infection As a result of DIC, the fibrinogen is consumed; therefore, there the levels of fibrinogen are decreased. When fibrinogen is consumed, it is broken down to fibrin degradation products, so this level increases. Thrombocytopenia also occurs due to the consumption and destruction of the platelets during this process. Symptoms include petechiae, ecchymosis, and bleeding from venipuncture sites. When the condition worsens, the symptoms can also include bleeding from surgical wounds and noninjured surfaces. Treatment is focused on managing the underlying cause of the DIC. High-risk patients and those who are actively bleeding should receive platelets to maintain a platelet count of at least 50,000. If patients are not bleeding, a platelet count of 20,000 is acceptable. Fresh frozen plasma and cryoprecipitate should be used in bleeding and high-risk patients to keep the international normalized ratio ≤2.0 and fibrinogen level >50 mg/dL. Heparin can be started with caution in patients who develop clinically evident thrombosis.

When a patient is in disseminated intravascular coagulopathy, the platelet levels are decreased, the fibrinogen level is decreased, and the fibrin degradation products are increased.

----- is a benign or malignant skin condition that manifests as symmetric, dark brown, velvety plaques in intertriginous areas. This is usually a result of hyperinsulinemia and insulin resistance secondary to diabetes, obesity, or PCOS. In nonobese patients, a work-up for possible gastrointestinal malignancy should be pursued.

aCANTHOSIS NIGRICANS

Bottom Line: Cystine renal stones are caused by a genetic defect in amino acid transport and are associated with ------ urine. COMBANK Insight : Patients with cystinuria usually present with renal colic. Uncommon presentations include hematuria, chronic backache, and urinary tract infection. A total of 25% of symptomatic patients report their first stone in the first decade of life, and another 30%-40% have their first experience as teenagers.

acidic This patient has cystine kidney stones. This is due to a genetic defect in the renal transport of certain amino acids; thus. a family history is consistent. Cystine stones are the least common type. Cystinuria is an autosomal-recessive defect in reabsorptive transport of cystine and the dibasic amino acids ornithine, arginine, and lysine from the luminal fluid of the renal proximal tubule and small intestine. The only phenotypic manifestation of cystinuria is cystine urolithiasis, which often recurs throughout an affected individual's lifetime. Surgical intervention may be necessary, but the cornerstones of treatment are dietary and medical prevention of recurrent stone formation.

House fires are a common cause of cyanide poisoning. Cyanide is produced from the combustion of certain materials like furniture during the course of a house fire. This poisoning may present with coma, seizures, heart dysfunction, metabolic acidosis, and breath that smells like bitter almonds. Metabolic acidosis occurs because cytochrome oxidase enzymes in the electron transport chain are inhibited, which leads to a shift from aerobic to anaerobic metabolism, which produces high levels of lactic acid. Cyanide poisoning may be treated with ----

amyl nitrite and thiosulfate.

Early symptoms of acute ------ toxicity include tinnitus, vertigo, nausea, vomiting, and diarrhea. Tinnitus, which this patient does not have, is very common. Symptoms associated with more severe toxicity include altered mental status, hyperpyrexia, noncardiac pulmonary edema, and coma. ABG would show a respiratory alkalosis early on, followed by an anion gap metabolic acidosis. Treatments may include activated charcoal, supplemental glucose, alkalinization of serum and urine, and hemodialysis.

aspirin

Risperidone and quetiapine are both ----antipsychotic medications used in the treatment of schizophrenia. This class of medications has been known to cause lethargy along with confusion and in high doses can prolong the QT interval. The concerning presentation of antipsychotic toxicity is neuroleptic malignant syndrome (NMS) which presents with fever, rigidity, mental status changes, and autonomic instability (tachycardia/tachypnea). This patient has no rigidity and has changes to the QRS duration would we be unexpected with antipsychotic overdose.

atypical

Sickle cell anemia is characterized as an --------disoder Other diseases with ----- inheritance include: cystic fibrosis, albinism, alpha-1 antitrypsin deficiency, phenylketonuria, thalassemias, glycogen storage diseases, and hemochromatosis.

autosomal recessive disorder.

Uterine atony is the leading cause of postpartum hemorrhage. Strong uterine massage with the simultaneous administration of intravenous oxytocin is the best initial treatment for uterine atony, after which ----- can be tried.

balloon tamponade The next best temporizing measure to address tone, after fundal massage and oxytocin with the addition of a second uterotonic medication (methylergonovine in this case), is balloon tamponade.

The most likely diagnosis is chronic myelogenous leukemia (CML). CML involves clonal expansion of myeloid progenitor cells. A leukocytosis with excess granulocytes and basophils may be seen. CML involves a ------, which forms the classic Philadelphia chromosome.

bcr-abl t(9;22) translocation Imatinib is a very commonly used medication for CML which means that you are likely to see it on your exam. Treatment for chronic myelogenous leukemia is imatinib or allogenic stem cell transplant, while the treatment for the blast phase of CML is dasatinib or stem cell transplant. First line treatment for CML is with imatinib or allogenic stem cell transplant while the treatment for the blast phase of CML is dasatinib or stem cell transplant. Imatinib targets and inhibits bcr-abl tyrosine kinase and eliminated the CML clone, leading to rapid hematologic and cytogenetic remission. Allogenic bone marrow transplantation is performed while the patient is in the chronic phase and may result in long-term survival. The best results occur in patients younger than 40 years old. Treatment may be complicated by graft-versus-host disease.

Altitude poisoning usually occurs in patients at sea levels above 8,000 feet. Risk factors for developing it include rapid ascent and extremely high altitudes. It presents with headaches, fatigue, dizziness, insomnia, acute pulmonary edema, ataxia, and stupor or coma. It is treated by immediately -------

descending to lower altitudes.

This elderly patient is on a beta-blocker and presenting with bradycardia, likely secondary to overdose of beta-blocker. Glucagon increases cardiac contractility, heart rate, and atrioventricular conduction. It is considered first-line treatment for beta-blocker toxicity. Other drugs to consider in beta-blocker toxicity include epinephrine for hypotension and atropine for bradycardia. Patients with symptoms that are unresponsive to pharmacologic therapy may require -----

cardiac pacing.

right upper quadrant pain, fever and jaundice

charcot triad-ascending cholangitis

Bottom Line: The first step in evaluation for ureteral damage during surgery is --------If the cause is not readily identifiable, other methods of assessment can be used, such as pyelography, dyes, or cystoscopy. Indigo carmine is no longer manufactured in the United States and has been replaced with sodium fluorescein.

direct visualization of the entire urinary tract.

----- intoxication causes tachycardia, hypertension, insomnia, mydriasis, aggression, psychosis, and "tactile hallucinations." It can also cause coronary vasospasm resulting in myocardial infarction.

cocaine COMLEX loves to ask you about toxicology scenarios on the exam, as it is a frequently encountered issue on the wards and in real-life practice. We have found the most commonly tested drugs to be (in no specific order): cocaine, opioids, PCP, LSD, benzodiazepines, barbiturates, caffeine, nicotine, amphetamines, alcohol and marijuana. The single most important thing you should know about each of these drugs-of-abuse is their unique physical exam findings.

his fracture in the exhibit is -----because it is broken in more than 2 pieces. It is ----- as the 2 fracture lines create a new segment. It is ---- because the 2 edges of the bone at the site of the break are not near anatomic alignment and they are almost overriding each other. Fractures can be described as open or closed. In ---fractures there is communication through the skin.

comminuted segmental displaced open

Seborrheic keratosis presents with benign lesions that appears as a greasy, "stuck on" papule or plaque, typically on hair-bearing areas. Management is with---- for irritated lesions, or reassurance of the patient if the lesions are not bothersome.

cryotherapy

: A vesicular lesion with a palpable preauricular lymph node is consistent with a Herpes Simplex Virus blepharoconjunctivitis. Topical steroids are contraindicated and may exacerbate corneal lesions.

true

: Choanal atresia presents with cyanosis that improves with crying and worsens with feeding. Diagnosis is conducted by inserting a catheter into the nasopharynx. If resistance is met, the diagnosis is made. Choanal atresia does not cause bilious vomiting.

true

COMBANK Insight : Marfan syndrome patients may experience upward lens dislocation whereas patients with homocystinuria may experience ------

downward lens dislocation. Marfan syndrome patients present with unique physical features due to an abnormality in the fibrillin gene including kyphoscoliosis, pectus excavatum, arachnodactyly, and upward dislocation of the lens in the eye. Patients with Marfan syndrome are at risk for an aortic aneurysm and dissection as well as cardiac arrhythmias.

Acetaminophen is the preferred pain reliever for patients with ---- Diclofenac, naproxen, and ibuprofen are NSAIDs associated with gastrointestinal bleeding and should be avoided in patients with hemophilia. Diclofenac, naproxen, and ibuprofen are NSAIDs associated with gastrointestinal bleeding and should be avoided in patients with hemophilia.

hemophilia Acetaminophen provides pain relief and does not affect bleeding. Hemophilia A is an inherited, X-linked, recessive disorder caused by deficiency of functional plasma clotting factor VIII. The treatment of hemophilia may involve management of hemostasis, management of bleeding episodes, use of factor replacement products and medications, treatment of patients with factor inhibitors, and treatment and rehabilitation of patients with hemophilia synovitis.

This patient has -------- an autosomal recessive disease characterized by pigmented skin, diabetes, and cirrhosis of the liver. It is caused by accumulation of iron leading to organ damage. Transferrin saturation will be increased.

hereditary hemochromatosis, Hereditary hemochromatosis is characterized by diabetes, skin pigmentation, and cirrhosis of the liver. It is caused by iron accumulation. Most patients are asymptomatic (75%) and are diagnosed when elevated serum iron levels are noted on a routine chemistry screening panel or when screening is performed because a relative is diagnosed with hemochromatosis. Early symptoms include severe fatigue (74%), impotence (45%), and arthralgia (44%); fatigue and arthralgia are the most common symptoms prompting a visit to a physician. The most common signs at the time of presentation are hepatomegaly (13%), skin pigmentation, and arthritis.

This patient has Turner syndrome. This disease is associated with coarctation of the aorta, which commonly presents with ------- In older adolescents and adults, presenting symptoms usually involve issues of puberty and fertility as well as short stature. Adrenarche, the beginning of pubic hair growth, occurs at a normal age and is not an indication that puberty will progress normally. Breast development is absent when ovarian failure occurs before puberty, but pubic hair growth is normal.

high blood pressure in the upper extremities and low pressure in the lower extremities.

Bloating, abdominal cramping, and flatulence after consuming dairy products are symptoms of lactose intolerance. The-------- is confirmatory, although lactose intolerance can usually be diagnosed based on clinical symptoms alone.

hydrogen breath test Native American adults have a lactose intolerance rate approaching 100%. This fact and the clinical symptoms of bloating, cramping, and flatulence after eating dairy products (ice cream) are enough to make the clinical diagnosis of lactose intolerance. If a confirmatory test is necessary, the best choice is a hydrogen breath test. This test is performed after an overnight fast when the patient is given 50 g of lactose. If the patient has a reduced or absent level of lactase, the lactose disaccharide cannot be broken down and absorbed in the bowel. Therefore, the enteric bacteria take on the responsibility of metabolizing lactose and, in the process, form hydrogen, methane, and carbon dioxide. Increased levels of these gases cause bowel distention with subsequent bloating, cramping, and flatulence and can be detected by gas chromatography in the breath of the patient.

more likely to be injured in the adolescent, sexually inexperienced population

hymen

Patients with Turner syndrome typically present with hypothyroidism (10% to 30% of patients with Turner syndrome) not hyperthyroidism. Proptosis is a physical exam sign in patients suffering from ------

hyperthyroidism/Graves disease.

Acrodermatitis enteropathica (AE)

is an autosomal recessive metabolism disorder of zinc deficiency that presents in childhood as a periorificial and acral dermatitis in addition to alopecia and diarrhea. This patient does not have the symptoms of alopecia and diarrhea that would likely be associated with this condition. Given the age of the patient, SSSS is more likely.

epididymitis

is an infection of the epididymis. It is usually caused by Escherichia coli in patients older than 35 years or Chlamydia in patients under the age of 35. Treatment consists of antibiotics.

The ---- is the most appropriate test to assess fetal limb development and cardiac function, given its extensive ability to view the heart.

level-II ultrasound The level-II ultrasound (targeted ultrasound or anatomy scan) is indicated in patients who are at high risk for congenital abnormalities. Lithium use during pregnancy has been associated with Ebstein anomaly, which is a congenital malformation of the heart caused by apical placement of the posterior and septal tricuspid leaflets. This leads to atrialization of the right ventricle. Ebstein anomaly presents with symptoms of heart failure. Medical therapy with surgical correction of the underlying tricuspid malformation is indicated.

A limbal dermoid is a choristoma, a benign congenital proliferation of mature tissue that is normally not present at that particular site. In contrast, a hamartoma is a benign congenital proliferation of mature tissue overgrowth that is normally located at that particular site. Limbal dermoids can be found in association with Goldenhar syndrome, also known as oculoauriculovertebral dysgenesis, and can present with a limbal dermoid, upper eyelid coloboma, vertebral anomaly, and preauricular skin tags.

limbal dermoid

In any patient with papilledema, neuroimaging (either computed tomography or magnetic resonance imaging) of the brain must be done before a ----

lumbar puncture. true The most likely diagnosis is pseudotumor cerebri (idiopathic elevated intracranial pressure). The clues are a young obese female taking isotretinoin (a vitamin A derivative) and oral contraceptive pills. The presence of papilledema is highly confirmatory for the diagnosis. Diuretics such as acetazolamide may be used for initial treatment to decrease cerebrospinal fluid (CSF) pressure. The surgical treatment includes placing a shunt that directs CSF away from the central nervous system. Optic nerve fenestration may be used in refractory cases to prevent blindness by relieving pressure on the optic nerve. Initial workup should be started with a computed tomography (CT) scan of the brain. Magnetic resonance imaging (MRI) is more sensitive for the diagnosis, but CT is quick and will rule out any emergent etiology. CT must be done before a lumbar puncture, which is diagnostic and therapeutic.

The first step after a positive finding on breast exam in an older female is to perform a ---------- in order to identify other abnormal lesions or patterns that may have been too small to detect on exam. In a younger female, an ultrasound may be a better choice for screening of a detected mass, in order to differentiate a solid versus cystic lesion (as mammographs are of lower utility in younger females due to the denser breast tissue).

mammogram, needle core biopsy is only appropriate once a mammography has been performed to rule out other possible lesions.

The flexor carpi radialis originates at the medial epicondyle of the humerus and inserts onto the base of the second metacarpal. This muscle is affected in -----(ie, golfer's elbow), not lateral epicondylitis.

medial epicondylitis

The flexor pollicis longus is innervated by the -----

median nerve.

A tram-track appearance of the basement membrane is due to subendothelial and mesangial deposits. This is commonly associated with ------

membranoproliferative nephropathy.

Lead poisoning can be caused by the ingestion of paint chips, working in battery or ammunition factories where lead is commonly used, consumption of moonshine made in lead-lined radiators, and working in factories that use lead-containing casting materials. It presents with ------- and ------- complaints.

neurologic and gastrointestinal complaints. Lead poisoning can be caused by the ingestion of paint chips, working in battery or ammunition factories where lead is commonly used, consumption of moonshine made in lead-lined radiators, and working in factories that use lead-containing casting materials. Lead denatures enzymes involved in hemoglobin synthesis such as ferrochelatase, ALA dehydrase, and ribonuclease. It can present with abdominal pain, diarrhea, encephalopathy, peripheral neuropathy, and renal failure. Lead is nephrotoxic and can damage the proximal renal tubules, leading to Fanconi syndrome. Lead poisoning is best treated with chelating agents such as succimer or dimercaprol.

A CT abdomen/pelvis may show enlarged lymph nodes secondary to underlying CLL, but would not otherwise be helpful. This patient has no significant hepatocellular abnormalities on his liver profile, no abdominal pain, and a normal US less than a month ago.

true

A child who goes to day care and presents with high fever and bloody diarrhea is likely suffering from Shigella. It is transmitted by the fecal-oral route and has a very low ID50 (infectious dose needed to cause disease in 50% of hosts); thus, it is easily transmitted from person to person.

true

A classic presentation of rickets is that of a dark-skinned, breastfed infant who has not had access to healthcare. The American Academy of Pediatricians recommends replacement of vitamin D at 400 IU/d in exclusively breastfed infants because breast milk is deficient in vitamin D. Lack of vitamin D results in rickets.

true

A commonly tested association is that of tinnitus as a symptom of Meniere's Disease, which is the triad of vertigo, hearing loss, and tinnitus.

true

A cryoglobulin screen could be considered due to the history of hepatitis C, however, cryoglobulinemia presents either as a vasculitis with a palpable rash, arthritis, and generally some kind of organ dysfunction, commonly renal or as a hyperviscosity syndrome resulting in headaches, hearing loss, and peripheral neuropathy. This patient has no renal dysfunction, no hyperviscosity symptoms, a non-palpable rash, and no complaints of arthritis making cryoglobulinemia very unlikely.

true

Extraintestinal manifestations: Anemia (10% to 15% of patients) is usually due to impaired absorption of iron or folate from the proximal small intestine. In severe celiac disease with ileal involvement, absorption of vitamin B12 might be impaired. A bleeding diathesis is usually caused by prothrombin deficiency due to impaired absorption of fat-soluble vitamin K. Osteopenia and osteoporosis (prevalence 1% to 34%) might cause bone pain for several reasons, including defective calcium transport by the diseased small intestine, vitamin D deficiency, and binding of luminal calcium and magnesium to unabsorbed dietary fatty acids. Neurologic symptoms (frequency 8% to 14%) that result from hypocalcemia include motor weakness, paresthesias with sensory loss, and ataxia. Seizures might develop because of cerebral calcifications. Skin disorders, including dermatitis herpetiformis (a pruritic papulovesicular skin lesion involving the extensor surfaces of the extremities, trunk, buttocks, scalp, and neck), are found in 10% to 20% of patients with celiac disease. Hormonal disorders, such as amenorrhea, delayed menarche, and infertility in women and impotence and infertility in men, have also been described.

of celiac diseae IgA endomysial antibody testing is moderately sensitive but highly specific for the diagnosis of untreated celiac disease and is considered the test of choice for detection of this disease. At the time of diagnosis, further investigations may be performed to identify complications, such as iron deficiency (by full blood count and iron studies), folic acid and vitamin B12 deficiency, and hypocalcemia (low calcium levels, often due to decreased vitamin D levels). Thyroid function tests may be requested during blood tests to identify hypothyroidism, which is more common in people with celiac disease. Osteopenia and osteoporosis, mildly and severely reduced bone mineral density, are often present in people with celiac disease, and investigations to measure bone density may be performed at diagnosis, such as dual-energy x-ray absorptiometry (DXA) scanning, to identify risk of fracture and need for bone protection medication.

Bottom Line: A CT scan of the abdomen and pelvis with intravenous and oral contrast is the best diagnostic test for acute diverticulitis.COMBANK Insight : Suspected diverticulitis without complications can be treated with -----antibiotics and outpatient followup. Failure of outpatient treatment requires hospitalization.

oral

Bullous pemphigoid is an autoimmune blistering disease that presents with tense blisters, most often in skin folds and flexural areas. Direct immunofluorescence of the skin will reveal immunoglobulin G (IgG) and C3 in a linear band at the basement membrane. The treatment of choice is -------

oral prednisone.

A young female with sudden lower abdominal pain and associated vomiting is likely to have ? and the next test to order is a ?

ovarian torsion pelvic ultrasound with Doppler.

The ------ is found halfway between the inferior lateral angle of the sacrum and the greater trochanter of the femur and can cause a radiating pain into the posterior thigh due to sciatic nerve impingement by a spastic piriformis muscle.

piriformis tenderpoint Piriformis syndrome can present as a burning sensation down the posterior and lateral thigh. It is caused by spasm of the piriformis muscle, which impinges the sciatic nerve. A piriformis tenderpoint can be associated with the presentation of piriformis syndrome; the tenderpoint for the piriformis muscle is located midline between the inferior lateral angle of the sacrum and the greater trochanter of the femur. In addition to addressing the piriformis muscle spasm with OMM, treatment also includes heat and cold modalities, progressive stretching, and muscle injections. Bottom Line: Strain-counterstrain is a passive indirect technique where the tissue being addressed, including muscles or tendons, is manuvered into a position away from a restrictive barrier. Counterstrain treatment positioning for pirifomis syndrome is prone with flexion, abduction, and external rotation of the right lower extremity.

Bottom Line: Painless vaginal bleeding in the 2nd or 3rd trimester is ----- until proven otherwise.

placenta previa This patient most likely has a placenta previa given her presentation. As such, the best method to diagnosis placenta previa is via ultrasound. Abdominal ultrasound is fast, safe and readily available. A screening ultrasound is usually performed at 18-20 weeks gestation. However, this patient has had no prenatal care. During an ultrasound, the physician should pay special attention to the location of the placenta. If the placenta is noted overlying the cervical os, the diagnosis is made. If the patient remains stable and her bleeding subsides, expectant management can be considered. However, if hemorrhage persists or worsens or there are signs of fetal distress, immediate delivery is warranted. As the placenta overlies the cervical os, vaginal delivery is not possible and the patient must undergo Cesarean delivery.

The ------ is recommended for AIDS patients; live vaccinations are contraindicated in the immunocompromised.

pneumococcal vaccine Live vaccines are contraindicated for immunocompromised patients and are not recommended for pregnant patients. Pneumococcus is the only vaccination in the list that is not live attenuated; it is a conjugate (polysaccharide components) vaccine as is Hemophilus influenzae B. The MMR vaccine may be used if CD4 > 200, but the general recommendation is to avoid all live vaccines. Killed vaccines include influenza, cholera, plague, polio, hepatitis A, and rabies. Toxoid vaccines include tetanus and diphtheria. Subunit vaccines include hepatitis B (surface proteins).

A lesion to the substantia nigra pars compacta (SNc) of the midbrain is what is commonly found in Parkinson's disease. This causes a resting tremor, not an intention tremor, and is associated with other signs and symptoms such as rigidity, bradykinesia, and postural instability.

true

Suspect ------ in a patient over the age of 50 years who presents with morning stiffness in the proximal musculature combined with fatigue, depression, and low-grade fever.

polymyalgia rheumatica Associated conditions include temporal arteritis, which presents with jaw pain, headaches, vision changes, and/or fatigue. There is no specific laboratory test to confirm the diagnosis of PMR, however, erythrocyte sedimentation rate and c-reactive protein will be elevated. Rheumatoid arthritis (RA) can also coexist with PMR and should be considered as a possible comorbid illness whenever PMR is diagnosed. Oral corticosteroids are considered to be the most effective therapy for patients suffering from polymyalgia rheumatica. The treatment of choice for PMR includes low-dose steroids, and patients improve rapidly. Some patients may report complete resolution of symptoms after only one dose. Commonly, prednisone doses of 10-20 mg daily are adequate to see resolution of pain and stiffness. These doses can then be tapered; however, most patients will be unable to stop steroids completely without return of their symptoms. If the patient's pain does not improve after two weeks of steroid treatment, the diagnosis of PMR should be brought into question.For patients who cannot successfully taper off steroid treatment, other options for long-term suppression include other commonly used disease-modifying drugs such as methotrexate.

The -------- is a branch of the radial nerve that supplies all of the extrinsic wrist extensors, except for the extensor carpi radialis longus. The posterior interosseous nerve may be entrapped at the arcade of Frohse, which is part of the supinator muscle. Posterior interosseous neuropathy is purely a motor syndrome resulting in finger drop and radial wrist deviation on extension. Radial nerve compression or injury may occur at any point along the anatomic course of the nerve and may have varied etiologies. The most frequent site of compression is in the proximal forearm in the area of the supinator muscle and involves the posterior interosseous branch. However, problems can occur proximally in relation to fractures of the humerus at the junction of the middle and proximal thirds, as well as distally on the radial aspect of the wrist. Radial nerve palsy in the middle third of the arm is characterized by palsy or paralysis of all extensors of the wrist and digits, as well as the forearm supinators. Very proximal lesions also may affect the triceps. Numbness occurs on the dorsoradial aspect of the hand and the dorsal aspect of the radial 3½ digits. Sensation over the distal and lateral forearm is supplied by the lateral antebrachial cutaneous nerve and therefore is preserved.

posterior interosseous nerve

Placenta previa is a condition characterized by the placenta overlying the cervical os. Placenta previa is predisposed by ----

prior C-section.

The extensor pollicis longus is innervated by the ----

radial nerve.

Patients with PSC are at a higher risk of developing cholangiocarcinoma and gallbladder cancer. A variety of screening exams are recommended including a yearly ----

right upper quadrant ultrasound. Diagnosis of psc is confirmed with multifocal strictures and segmental dilations seen by cholangiography. Liver biopsy is no longer recommended as outlined in the 2015 guidelines from the American College of Gastroenterology.

Treatment for Burkitt lymphoma is ------

rituximab. The most likely diagnosis is Burkitt lymphoma. Burkitt lymphoma is a type of non-Hodgkin lymphoma, which usually occurs in adolescents or young adults. It may have an association with Epstein-Barr virus (EBV), and is common in AIDS patients. It presents as a jaw lesion in the endemic form, which is common in Africa. The sporadic form is more common in the United States, and usually presents as an abdominal or pelvic mass. Biopsy of the mass often reveals sheets of lymphocytes with interspersed macrophages, also described as a starry sky appearance. The translation in Burkitt lymphoma is t(8;14) c-myc. The c-myc oncogene on chromosome 8 is translated next to the heavy chain Ig gene on chromosome 14. Treatment for Burkitt lymphoma is rituximab

A ----- involves any type of abortion in addition to signs of infection, such as fever, elevated WBC count, and lower abdominal pain.

septic abortion

Treatment consists of cooling, benzodiazepines, and supportive care. The use of cyproheptadine, a first-generation antihistamine with antiserotonergic effects, is controversial.

serotonin syndrome treatment

In generalized anxiety disorder the symptoms occur for at least--- and there is usually no identifiable stressor.

six months

Mercury poisoning can be caused by overconsumption of fish. It presents with diarrhea, constricted visual fields, renal failure, tachycardia, hypertension, peripheral neuropathy, and hyperhidrosis. It can be treated with chelating agents such as ----

succimer, dimercaprol, or penicillamine.

S2-S4 is where the parasympathetic viscerosomatic reflex for the penis is located. Recall that the parasympathetic nervous system is the branch of the autonomic nervous system responsible for erection. Priapism is an uncommon but clinically significant side effect of? Treatment includes administration of oxygen, injection of phenylephrine into the corpus cavernosa, and/or aspiration of blood from the corpus cavernosum.

trazodone.

1. Bone Marrow Biopsy 2. Refer to hematology and oncology This patient has diagnosed CLL with autoimmune hemolytic anemia which has responded to steroid treatment. He now presents for follow-up, and his repeat labs show a continued drop in his red blood cell and platelet count. Given that the patient no longer has scleral icterus, the peripheral smear shows no spherocytes, and the haptoglobin and LDH are normal; it can be assumed that the AIHA is under control and that there must be some other cause for the slow decline in blood and platelet counts. The patient's recent workup for anemia and thrombocytopenia reveled normal iron studies, B12, and folate, eliminating those as a possibility. It is also notable that the leukocyte count has continued to rise and that the patient's reticulocyte count is inappropriately low. This is concerning for primary bone marrow failure, likely secondary to infiltration by the clonal population of B-cells. To evaluate this possibility, this patient requires a bone marrow biopsy.Bottom Line: Unexplained anemia and thrombocytopenia in the setting of CLL (or any malignancy where bone marrow infiltration is a possibility) requires a bone marrow biopsy.

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5-HIAA is a metabolite of serotonin, testing is most frequently performed for the diagnosis of carcinoid tumors of the enterochromaffin (Kulchitsky) cells of the small intestine, which release large amounts of serotonin.

true

After conservative treatment fails for osteoarthritis of the hip, total hip arthroplasty is the most appropriate next step in management.

true

A medial meniscal tear occurs most commonly from a twisting injury with the foot planted. The knee contains 2 crescent-shaped menisci located between the femoral condyles and the tibial plateaus. The medial meniscus is firmly attached to the medial collateral ligament, thus it is not unusual to see both an MCL and medial meniscal injury concurrently. The arterial blood flow to the inner portions of the menisci are limited, thus this explains in part why most tears of the inner menisci do not heal. Patients with untreated meniscal tears can present weeks after the acute injury with complaints of popping, locking (unable to fully extend the knee secondary to interference from the torn meniscus), catching, or the knee "giving out."

true

A rupture of the proximal biceps tendon may present in a similar way to a rupture of the distal biceps tendon. Patients with proximal ruptures present with the "Popeye" deformity, which is evident upon contraction of the biceps with the elbow flexed to 90 degrees. The C5 reflex should be normal in patients with a proximal biceps tendon rupture. Furthermore, patients will complain of shoulder pain more commonly than elbow pain.

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A somato-somatic reflex occurs when a stimulus is applied to a somatic structure, which results in a response by another somatic structure, such as a tendon tap reflex.

true

A viscero-somatic reflex occurs when a visceral stimulus produces a reflex response to a segmentally related somatic structure. An example would be a heart attack causing palpatory changes in T1-T5; in this case, there is lung and pleural feedback producing a reflex response in T2-T7.

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A viscero-visceral reflex is a reflex in which sensory input from a visceral structure causes output in a different visceral organ. An example of this is pancreatitis causing increased gastric activity.

true

A young female patient with anterior knee pain without trauma likely has patellofemoral pain syndrome. Patella related pain is the single most common cause of knee pain. Patellofemoral pain syndrome is a multifactorial syndrome characterized by aching in the anterior knee that worsens with activities that stress the patellofemoral joint. The pain is thought to be caused by the patella not tracking correctly through the femoral groove. Activities that stress the patellofemoral joint include stair climbing, jumping, or prolonged sitting. Contributing factors to patellofemoral pain include weak gluteus muscles, increased Q angle at the knee, tight hamstrings, and weak quadriceps.Included in the differential is patellar tendonitis, patellofemoral arthritis, synovial plica, chondromalacia patellae, and patellar instability. A synovial plica is a redundant fold of synovial lining that can become painful and fibrotic. It usually occurs at the medial border of the patella. It can catch and become painful. Pain is usually medial of the patella. Patellar instability can cause a transient displacement of the patella (usually laterally). It can cause acute or chronic patellar pain. Pain is usually around the patella. Patellar tendinitis is the chronic wear of the patellar tendon. It causes anterior pain, below the patella. The patella is usually tender to the touch. Chondromalacia patellae is very similar to patellofemoral pain syndrome and is in part caused by maltracking of the patella through the femoral groove. The maltracking causes a softening and deterioration of the cartilage overtime behind the patella. Patellofemoral arthritis is arthritis that occurs at the patellofemoral joint. It will often be seen on x-rays as spurring on the patella on the lateral view or decreased joint space on the sunrise view (a view with the knee bent)

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AAAs 3-4 cm in diameter should be monitored with ultrasound every year. AAAs between 4-5.5 cm should be monitored with ultrasound every six months, and AAAs greater than 5.5 cm should be treated with surgery.

true

ASC-US is the most common cytological abnormality seen on Pap testing. They are reactive cells which are abnormal, but not definate for squamous intraepithelial lesion. The most appropriate management of a woman age 25 and older with an ASC-US is reflex HPV testing on an abnormal Pap smear result or repeat Pap smear in 1 year. Reflex HPV testing was not ordered with this patient's Pap smear so the alternative appropriate management is repeat Pap smear in one year.If cytology is negative, the patient can resume pap smear testing every 3 years.If patient again has an ASC-US, the next most appropriate step in management is a colposcopy. Additionally, if HPV testing had been performed and was positive, this patient would have been referred for colposcopy.

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Absent plantar flexion of the foot when the right calf is squeezed is a positive Thompson sign. A normal test would produce plantar flexion when the affected calf is squeezed. A positive Thompson sign is associated with Achilles tendon rupture.

true

Absolute contraindications to HVLA including osteoporosis, bony metastases, fracture in the area, rheumatoid arthritis, and Down syndrome.

true

Acetaminophen is another medication frequently used for headaches. Metabolism is primarily through the liver, and toxicity, treatment, and prognosis are related to the concentration ingested and the time from ingestion to initiation of therapy. This is plotted using the Rumack-Matthew nomogram. Although within 12 hours transaminase elevations may be detectable, within 24 hours, patients are generally asymptomatic. After this period, hepatic damage occurs with subsequent symptoms including anorexia, nausea, vomiting, and malaise. Although both salicylate and acetaminophen toxicity may cause encephalopathy, in this patient, key symptoms such as tinnitus and tachypnea would not be explained by acetaminophen toxicity.

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Adolescents are beginning to make decisions that can have life-long ramifications for their health, and it is essential to acknowledge the change in status as they transition from childhood to adulthood. Confidentiality is key to creating a trusting and therapeutic relationship between physician and patient. Taking a history in front of a parent or without assurances of confidentiality to the adolescent will often result in incomplete or inaccurate information and a lack of trust between patient and physician. It is standard practice to complete at least a portion of an adolescent interview without the parent in the room. This can present challenges to the therapeutic relationship between the parent and the pediatrician, and the physician must balance the need to alleviate the parent's concerns as well as protect the adolescent patient's need for privacy. Overall, the well-being of the patient trumps any potential issues that might arise from a parent's discomfort. Many physicians simply tell parents that it is standard care to complete some portion of the adolescent visit without them present. This can help alleviate any stress or concerns that their child is being treated differently.

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Alcohol withdrawal can look similar to BZD withdrawal and can be life threatening. Alcohol withdrawal is often treated with BZDs via a Clinical Institute Withdrawal Assessment for Alcohol (CIWA) scale in the inpatient setting. The most common BZDs used to treat alcohol withdrawal are diazepam (Valium), lorazepam (Ativan), and chlordiazepoxide (Librium). The CIWA assesses severity of alcohol withdrawal symptoms in patients by quantifying the following factors on a numerical scale:Nausea/vomiting,Tremor,Paroxysmal sweats/diaphoresis Anxiety, Agitation/restlessness, Tactile disturbances such as itching/pins and needles sensations/ tactile hallucinations, Auditory disturbances such as phonophobia to auditory hallucinations, Visual disturbances such as photophobia to visual hallucinations, Headache, Orientation to person, place, and time

true

All communication with a patient is best handled face-to-face. When this is not possible because of the need to deliver news in a timely manner, as in the present case, the phone conversation should be followed up by a visit. The follow-up visit is also needed to discuss some of the patient's other health issues, including his weight. This patient's body mass index (weight/height) is too high.

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All of the signs and symptoms given in this case point to the diagnosis of Psoas syndrome, which is typical in athletes requiring repeated hip flexion, such as runners, dancers, and gymnasts. Psoas syndrome commonly presents as pain and stiffness in the hip and thigh region. A "snapping" feeling is also frequently reported, which is caused by the iliopsoas tendon catching on the pelvis when the hip is flexed. The Thomas test is used to detect hip flexor contracture and tightness. It is performed with a patient lying supine, then fully flexing the knee and hip of the contralateral leg and monitoring for simultaneous passive hip flexion of the ipsilateral hip. A positive test is passive hip flexion contracture, which indicates tight hip flexors. Typical osteopathic findings include a tender point medial to the ipsilateral ASIS, a positive pelvic shift test to the contralateral side, sacral dysfunction on an oblique axis, a positive Thomas test, and spasm of the contralateral piriformis muscle.

true

Almost all burn resuscitation strategies are conducted with crystalloid solutions within the initial 24-hour period following burn injury. Lactated Ringer's solution is the preferred treatment given that it is isotonic. It is preferable to isotonic sodium chloride because of its lower sodium concentration and higher pH, which are closer to physiologic levels. Lactated Ringer's solution also acts as a buffer for metabolized lactate that is present during the ensuing metabolic acidosis following burn injury.Administration of fluids should follow the Parkland formula, which advocates the guideline for total volume in the first 24 hours of resuscitation at approximately 4 mL/kg body weight multiplied by the percentage of body surface area (BSA) burned. With this formula, half the volume is given in the first 8 hours, with the remaining volume delivered over 16 hours.

true

Alprazolam is a benzodiazepine but it is not used for seizures. Both lorazepam and diazepam are benzodiazepines that are FDA approved for seizures. Lorazepam is first line and diazepam should be used if lorazepam is not available. Alprazolam is used for panic attacks.

true

Although oral contraceptive pills (OCPs) are helpful in menorrhagia, this patient has shown non-adherence in the past and therefore you should avoid daily medications.It is also important to remember that because these pills contain estrogen not all women are eligible. Reasons to avoid an OCP include: Age ≥35 years and smoking ≥15 cigarettes per day Multiple risk factors for arterial cardiovascular disease or known ischemic heart disease or valvular disease History of venous thromboembolism or stroke Current breast cancer Severe liver disease or cancer Migraine with aura Diabetes mellitus of >20 years duration or with complications

true

Although the child demonstrates both gross and fine motor skills consistent with that of a 6-month-old, his language development is more advanced. At 9 months of age, children are expected to begin to say "dada" and "mama" and understand the meaning of "no." A 4-month-old should be oriented to voice, while a 6-month-old should begin to "babble." At 1 year of age, you would expect to see a 1- to 8-word vocabulary with words other than "dada" and "mama," and 1-step commands should be followed.

true

Although the mechanism of epithelial injury in giardiasis is unclear, this question is still fair game. A best guess can be made by knowing that Giardia causes greasy, foul-smelling stools; the foul smell is caused by increased fat in the stool. The stool may float, stick to the side of the toilet bowl, or be difficult to flush away.

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Although the platelet count will be decreased, fibrinogen level will also be decreased and fibrin degradation products will be increased in DIC. Fibrinogen is an acute-phase reactant and will initially be elevated in this patient with an underlying infectious condition. However, as the disease progresses, the consumptive process of the DIC will result in low levels of fibrinogen. The fibrin degradation products will be increased in DIC due to the fibrinolytic activity at the sites of thrombus formation. The high number of fibrin degradation products interfere with fibrin clot formation and platelet aggregation, further exacerbating hemorrhage.

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An injection site reaction commonly presents after an injection and presents with local symptoms of erythema, tenderness, and irritation at the injection site. Treatment includes ice and reassurance. Often, allergic and flare reactions happen with subcutaneous immunotherapy (SCIT) injections and vaccinations. Please refer to the UpToDate article on the administration techniques of SCIT injections for more information on common injection site reactions.For more information, see:UpToDate, SCIT: Standard schedules, administration techniques, and monitoring

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An interventricular septal rupture usually occurs 5 to 10 days after MI and may present with a holosystolic murmur best heard along the left sternal border.

true

Anticentromere antibodies are the classic clue for CREST syndrome. The E in CREST stands for esophageal dysmotility, which would present with difficulty swallowing (dysphagia).

true

Antithrombin III deficiency is a cause of a hypercoagulable state. It would cause signs and symptoms of clotting, not bleeding.

true

Aortic stenosis is a common cause of angina and dyspnea. Outflow obstruction decreases blood flow to the brain causing syncope. Syncope from aortic stenosis usually presents during exertion. Treatment is eventual aortic valve replacement. Ideal medical therapy for comorbid conditions will maximize the compensated time before valve replacement is necessary.

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An intracranial abscess may be seen in bacterial, fungal, and parasitic infections. Common sources include an extension from sinusitis, mastoiditis, or tooth disease. Direct extension from an epidural or meningeal infection can also be a cause. Hematogenous spread can occur from extracranial sources. This is typically manifested by focal ring-enhancing lesions within the brain parenchyma. The image in the exhibit does not display focal rim-enhancing lesions. Common presenting symptoms include seizure, febrile illness, headache, and focal neurologic deficits. Treatment consists of surgical excision and drainage, with antibiotics only if the abscess is small and steroids to minimize edema and mass effect. Computed tomography (CT) examination with contrast and magnetic resonance imaging (MRI) with gadolinium are the best studies to determine if an intracerebral abscess is present.

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Anatomical incontinence is the involuntary release of urine related to structural problems of the urinary tract that affect the urine flow. Anatomical incontinence may be present from birth (congenital).The main symptom of anatomical incontinence is an almost continual release of urine. Anatomical incontinence is caused by structural problems in the urinary tract that allow urine to leak past the muscle (sphincter) that retains urine in the bladder. These problems include: An abnormal pouch (diverticulum) in the wall of the urethra. Urine can become trapped in the pouch and then leak out. An abnormal opening between the bladder and vagina (vesicovaginal fistula) or between a ureter and the vagina (ureterovaginal fistula). Treatment of anatomical incontinence concentrates on correcting the structural problem that is interfering with the bladder's retention of urine.

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Angiodysplasia, sometimes also called arteriovenous malformations (AVMs), are fragile, dilated, tortuous vessels in the gastrointestinal (GI) tract most commonly located in the proximal colon. These vessels can rupture and are a common cause of a GI bleed in the elderly. It is more commonly seen in patients with von Willebrand disease. Small bowel AVMs are associated with Heyde syndrome, in which aortic stenosis causes an acquired von Willebrand disease with the subsequent development of AVMs and mucosal bleeding. They are generally painless and would not cause nausea or vomiting.

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Angiotensin-converting enzyme (ACE) inhibitor-induced hyperkalemia is the most likely cause of this patient's ECG findings. The ECG shows peaked T waves, which are most obvious in leads V4, V5, and V6. ACE inhibitors block angiotensin formation, thus decreasing secretion of aldosterone. Aldosterone induces reabsorption of sodium and chloride and excretion of potassium in the distal tubule, which is why decreasing secretion of aldosterone leads to decreased excretion of potassium and results in hyperkalemia. Most cases of hyperkalemia are asymptomatic if there has been a slow rise in serum potassium levels. Generally, severe ECG changes are not noticed until levels reach 6.5 mEq/L or greater. Sequence of ECG changes that occur with progressive hyperkalemia:- Peaked T waves and short QT interval- Progressive lengthening of PR and QRS intervals- Loss of P wave plus QRS widening and eventual development of a "sine wave" pattern- Ventricular fibrillation or cardiac arrest

true

Ankle injuries commonly lead to fibular fractures. The superficial peroneal nerve supplies sensation to the dorsum of the foot and can be injured in distal fibular fractures.

true

Answer A: Astrocytoma is a primary neoplasm of the brain developing from cells of astrocytic origin. The tumor is well-differentiated but is intra-axial, causing infiltration throughout the brain tissue. Different grades of astrocytoma are classified according to the growth pattern, ranging from WHO grade II to IV, which is a glioblastoma multiforme. Symptoms are generally related to a seizure and neurologic deficits. Treatment is primarily surgical. Transformation to higher grade neoplasm is a concern for long-term survival. The exhibit does not reveal a primarily infiltrative mass within the brain; thus, astrocytoma would be low on the differential diagnosis.

true

Answer A: CT scanning is the preferred modality to assess the extent of the tumor in the abdominopelvic cavity. CT scanning can also be useful for finding omental caking or differentiating fluid from solid tumor in the abdomen, especially in tumors with low malignant potential. However, CT scanning should not be used for routine screening of ovarian cancer.Answer B: Laparotomy with tissue sent for microscopic analysis is the definitive procedure used to diagnose ovarian cancer. However, it is not the first step in evaluating a patient for ovarian cancer.Answer C: The CA-125 test is not recommended as a screening test for ovarian cancer at this time because it often has false-positive results. However, the CA-125 test and a transvaginal ultrasound may be used to test women who have a high chance of developing ovarian cancer (ie, family history of ovarian cancer, BRCA1/2 gene positive). This should not be the first step in evaluating a patient.Answer D: Pap smears are useful for detecting cervical and uterine cancer but do not aid in the detection of cancer of the ovary.

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Answer A: Dilated cardiomyopathy is typically seen in elderly patients and manifests with gradual development of left- and right-sided heart failure. Symptoms include dyspnea on exertion, fatigue, orthopnea, and palpitations. Dilated cardiomyopathy is characterized by systolic dysfunction.

true

Answer A: Hyperthyroidism in a newborn presents with small head circumference, tachycardia, tremors, and poor weight gain. Treatment is with anti-thyroid medications, thyroid ablation, or subtotal thyroidectomy.Answer C: Hemolytic disease of the newborn can be caused by Rh system antibodies and ABO system antibodies. Common findings are jaundice, pallor, hepatosplenomegaly, and fetal hydrops (in severe cases). Treatment is exchange transfusion, phototherapy, and IVIG if given early in the course.Answer D: Neonatal abstinence syndrome (NAS) normally presents within 3-5 days of life. Typical signs and symptoms include: high-pitched cry, restlessness, hyperactive reflexes, tremors, sweating, and GI dysfunction. Treatment is supportive and naloxone should be avoided. Substitutes (e.g. morphine, methadone) can provide symptomatic relief.Answer E: Neonatal hyperglycemia is rare. Hypoglycemia is associated with macrosomia and gestational diabetes. Treatment is glucose control.

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Answer A: Routine HPV vaccine administration is for boys and girls ages 11 and 12. It may be started at age 9. For adolescents and adults aged 13 to 26 years who have not been previously vaccinated or who have not completed the vaccine series, catch-up vaccination is recommended. For adults 27 years and older, catch-up vaccination is not routinely recommended. According to the ACIP, the decision to vaccinate people in this age group should be made on an individual basis. While it is approved up to age 45 as of 2018, most insurers will not pay for it after age 26.

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Answer A: The Chlamydia pneumoniae organism is not typically seen in infants but more so in young adults or elderly populations. It presents with bronchitis symptoms, fever, and rales/rhonchi. It is considered an atypical pneumonia and may have a less severe manifestation.Answer B: Chlamydophila psittaci is associated with bird exposure, such as with pet shop employees. It presents with fever without an elevated pulse, somnolence, and splenomegaly.Answer D: Hantavirus infection can follow rodent exposure and almost never affects infants. It starts with typical viral symptoms (fever, headache, myalgias) and evolves to a cardiopulmonary phase that can cause dyspnea, nonproductive cough, and circulatory collapse. Hantavirus is fairly rare, and there is no specific treatment or cure.Answer E: Streptococcus pneumoniae can affect infants and cause pneumonia, but it is not associated with conjunctivitis. Group B strep is a very common cause of early onset pneumonia (chlamydia is considered late onset). X-ray findings of GBS pneumonia include a diffuse alveolar pattern that can be difficult to distinguish from hyaline membrane disease or transient tachypnea of the newborn. It presents with tachypnea, grunting, hypoxia, and increased work of breathing. Treatment is typically ampicillin. While Streptococcus pneumoniae may be a more common cause of neonatal pneumonia, it does not fit with the presentation of this patient.

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Answer B: A flexion/extension straining pattern occurs when the cranium is restricted in either flexion or extension (named for the direction of ease). This is diagnosed by observing asymmetry while palpating the CRI.

true

Answer B: Cheyne-Stokes respirations differ from Biot respirations, also known as cluster breathing. In Biot respirations, groups of quick and shallow inspirations (hyperpnea) are followed by periods of apnea. These respirations include a uniform tidal volume with each respiration, whereas Cheyne-Stokes involves gradual increases in tidal volume during the hyperpnea phase. Biot respirations occur following damage to the pons due to strokes or trauma or by pressure on the pons due to uncal or tentorial herniation.

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Answer C: An intravenous pyelogram (IVP) may also detect bladder diverticula and is particularly useful in those that protrude laterally. IVP is limited in that anteriorly or posteriorly placed diverticula may be obscured from view because they are overshadowed by the contrast within the bladder.

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Answer C: Gamma-glutamyl transferase (GGT) is an enzyme that is found in the liver. It may be found to be elevated in the serum in diseases of the liver, biliary tract, and pancreas. It reflects the same spectrum of hepatobiliary disease as alkaline phosphatase, 5'-nucleotidase, and leucine aminopeptidase. In contrast to alkaline phosphatase, GGT activity is not increased in patients with bone disease. An isolated elevation in serum GGT or a GGT elevation out of proportion to that of other enzymes may be an indicator of alcohol abuse or alcoholic liver disease. In a patient with ascending cholangitis, GGT will be elevated.

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Answer C: Iliotibial band syndrome is a cause of lateral hip pain. The iliotibial band starts at the anterolateral iliac tubercle portion of the external lip of the iliac crest and inserts on the lateral condyle of the tibia. Pain is generally around the lateral hip or the lateral knee. Patients may experience clicking at either of those locations. Treatment is typically conservative with physical therapy and anti-inflammatories.

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Answer C: Projection is demonstrated when an individual attributes his or her own personally unacceptable ideas to others. An example would be a homophobic teenager who believes that his teacher is a homophobe.

true

Answer D: For the Speed test, the patient fully extends the elbow, flexes the shoulder, and supinates the forearm. The examiner resists the flexion at the shoulder. This tests for injury to the biceps tendon in the forearm.

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Answer D: Pancreatitis is an inflammation of the pancreas. Patients with pancreatitis typically have epigastric pain radiating to the back. This is a rare condition in a 14-year-old patient. The mnemonic GET SMASHED can be helpful to remember the causes of pancreatitis.G: gallstones, genetic—cystic fibrosisE: ethanol (alcohol)T: traumaS: steroidsM: mumps (and other infections)/malignancyA: autoimmuneS: scorpion stings/spider bitesH: hyperlipidemia/hypercalcemia/hyperparathyroidism (metabolic disorders)E: endoscopic retrograde cholangiopancreatographyD: drugs

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Answer D: Regression occurs when patients revert to behavior patterns consistent with someone of a younger age. An example would be a six-year old who is toilet-trained and begins to wet the bed after his mother delivers a new baby.

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Answer E: Age-related changes to the natural lens of the eye can lead to various types of cataracts. Nuclear sclerotic cataracts can cause a slowly progressive deterioration of visual acuity that may be corrected with the use of spectacles or surgical extraction. Visual field loss is not a characteristic finding. Patients may note difficulty with near and distance vision. Optical aberrations such as halos or glare, decreased contrast, and yellowing of vision can be observed in this central opacification of the natural lens.

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Answer E: Reiter syndrome, also known as reactive arthritis, has three components: postinfectious arthritis, urethritis, and conjunctivitis ("can't see, pee, or climb a tree"). Typical pathogens include Campylobacter, Salmonella, Shigella, and Chlamydia trachomatis. The arthritis is usually asymmetric and involving the lower extremities. Management is with NSAIDs.

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Answer E: Streptococcal pharyngitis is associated with the Centor criteria, mainly throat pain with erythema or tonsillar exudates, cervical adenopathy, fevers, and lack of cough. This patient has throat pain; however, the exam is not consistent with pharyngitis. There is no adenopathy and no erythema or tonsillar exudates. Therefore, streptococcal pharyngitis is unlikely.

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Answer E: The piriformis is a muscle that originates on the sacrum and attaches on the greater trochanter. A strain of this muscle typically causes posterior hip pain. Treatment is conservative with physical therapy and anti-inflammatories.

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Anterior cruciate ligament (ACL) tears are typically associated with a trauma to the knee. Plain radiographs are usually negative in ligamentous injuries like an ACL tear. Occasionally a fracture of the lateral tibial condyle may occur as a result of avulsion of the lateral capsule, commonly called a segond fracture.

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Ascites has a stepwise treatment beginning with alcohol cessation, NSAID avoidance, and salt restriction. If this fails, then therapy with spironolactone and furosemide can be utilized followed by large volume paracentesis with albumin infusion. TIPS is the next step and if this does not achieve a positive response then liver transplant is the next choice.

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Atropine is used for acute, temporary symptom relief of organophosphate poisoning; pralidoxime is the only antidote, but must be given quickly or else it will not work.

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Autism disorder has a more insidious onset, and parents often have a hard time describing a specific time when they first noticed symptoms.

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Autosomal- dominant polycystic kidney disease (ADPKD) is associated with multiple renal cysts. These cysts are much more plentiful than what is observed in the renal tissue of persons with VHL disease. In ADPKD, the renal architecture is markedly distorted, adversely affecting renal function. The risk for malignant change is low in persons with ADPKD. CNS lesions are seen in both ADPKD and VHL disease; however, the lesions in ADPKD consist of arterial aneurysms, not hemangioblastomas, as seen in VHL disease. Hepatic cysts are common in ADPKD but rare in VHL disease, whereas pancreatic cysts are rare in ADPKD and common in VHL disease (as seen in the ultrasound of this patient).

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Bacterial vaginosis: Not a sexually transmitted disease, caused by overgrowth of normal flora; positive whiff test, vaginal pH >4.5, clue cells; treated with metronidazole Candidiasis: Associated with diabetes mellitus, pregnancy, and use of antibiotics; red/pruritic tissue, cottage cheese discharge, normal vaginal pH, pseudohyphae; treated with topical or oral antifungals (-azoles)Trichomonas: Sexually transmitted; strawberry cervix, copious malodorous frothy discharge, flagellated organisms on wet smear; treated with metronidazoleAnswer A: Oral doxycycline is the preferred treatment for lymphogranuloma venereum, caused by infection with Chlamydia trachomatis.Answer C: Oral metronidazole is the preferred treatment for vaginitis caused by either Trichomonas vaginalis or Gardnerella vaginalis.Answers D & E: Both ketoconazole and fluconazole can be given topically for the treatment of vaginal candidiasis, but treatment is generally with an oral agent.

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Besides varices, other major complications of cirrhosis include ascites, spontaneous bacterial peritonitis, hepatic encephalopathy, hepatocellular carcinoma, hepatorenal syndrome, hepatopulmonary syndrome.

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Blood cultures are commonly positive in about 50% of patients with osteomyelitis and can be used to confirm the organism responsible for the infection. Staph aureus is the most common organism found in patients with osteomyelitis. Blood cultures should clear with appropriate antibiotic treatment. If blood cultures are persistently positive then there is likely an alternative nidus for infection or inadequate source control. They are not useful for monitoring short response to infection as they take days to grow, are labor intensive, and can be negative even with continued infection due to the suppressive effect of antibiotics.

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Both FSH and LH levels remain normal in patients with Asherman's syndrome due to the preservation of normal ovarian function.

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Both radical and modified radical mastectomies involve the removal of all breast tissue, along with ipsilateral axillary lymph nodes. Radical mastectomies involve removal of the pectoralis major and minor as well.

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Bottom Line: A PPI such as omeprazole or H2 blocker like famotidine is indicated as a first line pharmacologic treatment for patients with GERD.

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Bottom Line: A bicornuate uterus can lead to recurrent spontaneous abortions and should be considered in patients with a long-standing history of dyspareunia, dysmenorrhea, cyclic pelvic pain, and infertility issues.

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Bottom Line: A pancreatic pseudocyst is an accumulation of pancreatic fluid that may be seen weeks after a bout of acute pancreatitis. Most resolve spontaneously within 6 weeks. COMBANK Insight : Pancreatic pseudocysts are the most common cystic lesions of the pancreas, accounting for 75-80% of such masses.

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Bottom Line: A patient over 65 should be updated on pneumonia, Tdap, and shingles vaccines. When in season, a flu shot should be given as well.

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Bottom Line: A patient who presents with respiratory distress following surgery for chronic airway obstruction should be immediately evaluated for negative pressure pulmonary edema.

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Bottom Line: A patient with jaundice and weight loss should be considered to have periampullary malignancy until proven otherwise. The most common malignancy is pancreatic adenocarcinoma, and it can cause cholangitis.

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Bottom Line: ACEI/ARBs, aldosterone antagonists, beta blockers, hydralazine/nitrates, and sacubitril/valsartan, all improve mortality in patients with HFrEF.COMBANK Insight : Knowing which drugs improve MORTALITY will be helpful on the comlex. Commit these to memory.

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Bottom Line: Acetaminophen is the first-line treatment for migraines during pregnancy.COMBANK Insight : Many drugs should not be used in pregnant patients. Preventing morbidity and mortality is a large component of COMLEX Level 3.

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Bottom Line: Acromegaly presents with symptoms secondary to the overproduction of growth hormone, which is often caused by a pituitary adenoma.

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Bottom Line: An anterior ST-segment elevation myocardial infarction results from occlusion of the left anterior descending artery (LAD) and is characterized by ST-segment elevation with Q-wave formation in the precordial leads (V1-V6) ± the high lateral leads (I and aVL) and reciprocal ST depression in the inferior leads (III and aVF).

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Bottom Line: An upper gastrointestinal series is the most appropriate initial test for suspected gastroparesis. Management of diabetic neuropathy should begin at the initial diagnosis of diabetes. The primary care physician needs to be alert for the development of neuropathy—or even its presence at the time of initial diabetes diagnosis—because failure to diagnose diabetic polyneuropathy can lead to serious consequences, including disability and amputation.

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Bottom Line: Anemia in an adult male is of gastrointestinal origin until proven otherwise. It is important to follow-up episodes of diverticulitis with colonoscopy at least eight weeks following the resolution of the diverticulitis.COMBANK Insight : Other common clinical presentations include iron-deficiency anemia, rectal bleeding, abdominal pain, change in bowel habits, and intestinal obstruction or perforation. Right-sided lesions are more likely to bleed and cause diarrhea while left-sided tumors are usually detected later and could present with bowel obstruction.

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Bottom Line: Babinski sign tests for a central lesion, and a normal response is plantar flexion of the toes in an adult

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Bottom Line: Characteristic ECG findings of Wolff-Parkinson-White syndrome are shortened PR interval and delta waves at the onset of wide, slurred, QRS complexes. Failure to recognize this dysrhythmia and treatment with certain agents (eg, beta-blockers, calcium channel blockers, digoxin) may lead to clinical deterioration.COMBANK Insight : In certain cases, especially if the patient is asymptomatic and you are dealing with incidental findings, do not overlook the importance of education and/or lifestyle modifications before proceeding to more invasive options.

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Bottom Line: Cheyne-Stokes breathing is characterized by oscillating periods of apnea and hyperpnea. It is noted in patients with congestive heart failure and central nervous system abnormalities.COMBANK Insight : Breathing patterns may seem like an obscure topic; however, they have shown up on exams before. It is best to learn them before your test day.

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Bottom Line: Combination therapy with IM ceftriaxone and oral doxycycline is recommended in patients with pelvic inflammatory disease (PID) to cover for both Neisseria and Chlamydia spp.COMBANK Insight : Follow the guide below for pelvic inflammatory disorder treatment on COMLEX: Cultured Chlamydia: Treat with oral doxycycline only. Cultured Neisseria gonorrhoeae: Treat with ceftriaxone AND doxycycline due to the high rate of co-infection of Neisseria with Chlamydia. Chlamydia is an obligate intracellular organism and can be difficult to culture, leading to false negatives. Unknown etiology: Treat with ceftriaxone AND doxycycline.

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Bottom Line: Common side effects for furosemide include hypokalemia, hyperuricemia, hypomagnesemia, allergic reactions, and hypocalcemia.COMBANK Insight : Basic physiologic changes secondary to diuretic use are commonly tested. Diuretics are commonly used medications, and it is important to understand how they work and the side effects they can cause.

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Bottom Line: Compression of cranial nerves IX, X and XII can lead to poor suckling in the newborn; cranial nerves IX and X can be compressed at the jugular foramen, and cranial nerve XII can be compressed at the hypoglossal canal.COMBANK Insight : Cranial questions, while not extensively studied by research, will show up on your exam. Focus your studying on the cranial chapter in Savarese's review book.

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Bottom Line: Conservative therapy with correction of underlying pathologies is the most appropriate initial treatment for patients suffering from claudication.COMBANK Insight : COMLEX exams focus a lot on treatment strategies. However, most questions are geared toward management in a primary care setting. When approaching questions, think like a primary care physician and what is least invasive.

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Bottom Line: Corticosteroids are the mainstay treatment for dermatomyositis.COMBANK Insight : There are usually a significant number of rheumatologic cases dealing with myopathies on COMLEX level 3. Know how to differentiate these disorders based on their characteristic features. You'll typically be given a multi-step case that involves making a correct diagnosis, identifying characteristic findings/laboratory values/etc, and then choosing the correct treatment plan.

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Bottom Line: Creatine kinase and aldolase levels are the most commonly elevated enzymes in patients with dermatomyositis.COMBANK Insight : There are usually a significant number of rheumatologic cases dealing with myopathies on COMLEX 3. Know how to differentiate these disorders based on their characteristic features. You'll typically be given a multistep case that involves making a correct diagnosis, identifying characteristic findings/laboratory values, and then choosing the correct treatment plan.

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Bottom Line: Diabetic ketoacidosis can predispose a patient to many opportunistic infections. A necrotizing infection extending into the orbit from the nasopharynx must be evaluated promptly because it is a potentially life-threatening condition.COMBANK Insight : Remember mucormycosis and Rhizopus species as associated with diabetes mellitus.

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Bottom Line: Diffuse ST elevation with depression of the PR segment is the classic ECG finding in acute pericarditis. Although it is not always present, it should be recognized as a classic finding in acute pericarditis. If ST elevation is seen on ECG, a full workup is required to rule out myocardial infarction.

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Bottom Line: Duodenal atresia refers to the congenital absence or complete closure of a portion of the duodenal lumen.COMBANK Insight : Congenital malformations of the GI tract are a COMLEX favorite and routinely appear in some format in the pediatric portion of the exam. This topic is routinely tested in a matching format similar to what is shown above. Make sure you are able to distinguish between these based on presentations alone.

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Bottom Line: Focal nodular hyperplasia appears on CT scanning as a hypervascular mass containing arteriovenous connections.COMBANK Insight : Benign liver masses, from most common to least common, include hemangiomas (or hemangiomata), hepatic adenomas, focal nodular hyperplasia, and hepatic cysts.

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Bottom Line: HLA-DR3 and HLA-DR4 genomic haplotypes are commonly associated with juvenile insulin-dependent diabetes and autoimmune hepatitis.COMBANK Insight : Even if the test taker is uncertain of the HLA association of both DM-1 and autoimmune hepatitis, the common factors of all of the other answers should help highlight autoimmune hepatitis as a unique answer choice, and thereby warrant particular consideration. Additionally, the general idea of "autoimmune" conditions being associated with other "autoimmune" conditions, such as pernicious anemia and alopecia areata is also highly testable. In addition to HLA subtypes of HLA-DR3 and DR4 associated with autoimmune hepatitis, a very commonly tested association is positive anti-smooth muscle antibodies.

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Bottom Line: Hydroflouric acid burns should be initially treated with copious irrigation with tap water, followed by calcium gluconate gel application.

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Bottom Line: If a patient in status epilepticus does not respond to lorazepam, then fosphenytoin, phenytoin, valproic acid, or levetiracetam is given as the next step.COMBANK Insight : Note that it may be confusing that midazolam is in the algorithm twice. It is used as a first line medication for seizures only if IV access is not available. It is again in the algorithm as a third step if the patient has failed lorazepam, and fosphenytoin, phenytoin, valproic acid, or levetiracetam. It may be given as an infusion once the patient is intubated to help control seizures. For COMLEX, be sure to know which medications are used to treat acute seizure and status epilepticus and the order in which to use them.

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Bottom Line: If you have a patient who needs therapy and a consultant is unwilling to treat, it is necessary to refer the patient to another consultant for care.COMBANK Insight : Although HIV was used in the above scenario, this situation could be applied to any case where a consultant refuses care. It is your job to always think in the best interest of the patient. It is also important to always maintain the utmost professionalism in the physician-patient relationship. Other contraindications for use of the pedal pump technique include the presence of a deep venous thrombosis and recent fractures in the lower extremities.

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Bottom Line: In a patient with advance directives, there is no need for the hospital ethics committee to become involved, and a family meeting to determine the patient's wishes is unnecessary as they are clearly stated in the advance directive. Conversations with family should always be unbiased on the patient's behalf.

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Bottom Line: In a patient with pheochromocytoma and adrenal mass, you must pretreat with alpha/beta blockade prior to surgical resection of the mass.COMBANK Insight : COMLEX will frequently test you on the next best step in the workup of a patient with a certain clinical presentation. It is important to know the algorithms for each clinical presentation with which you may be presented.

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Bottom Line: In patients with mild hypothermia, passive rewarming is the initial management step of choice. If passive rewarming fails or is expected to fail and "rewarming shock" is not a concern, then active external rewarming should be implemented.

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Bottom Line: In renal failure patients, hyperkalemia is a common occurence, and succinylcholine results in an increase in serum potassium levels in normal subjects by 0.5 to 2 mEq/L. Given this fact, succinylcholine should not be used in patients with preexisting hyperkalemia.

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Bottom Line: In suspected abruption, initial evaluation requires assessment of the mother and fetus. If the mother is stable, fetal evaluation is the next best step in management.

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Bottom Line: Indirect inguinal hernia occurs more commonly in young males. Exam findings include pain, when a person coughs, bends, or lifts a heavy object; a bulge on either side of the pubic bone; and a burning or aching sensation at the bulge.COMBANK Insight : Understand the application of common physical exam findings within a correct patient age group to determine a diagnosis.

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Bottom Line: Initial antihypertensive treatment should include a thiazide diuretic, calcium channel blocker, ACE inhibitor, or ARB in the general nonblack population, or a thiazide diuretic or calcium channel blocker in the general black population.

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Bottom Line: Lateral epicondylitis is an overuse injury with tenderness focal to the lateral epicondyle and is due to an injury to the common extensor tendon and most involved is the extensor carpi radialis brevis tendon.

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Bottom Line: Leriche syndrome is a subtype of peripheral artery disease that involves pathology of the aortoiliac arterial system. COMBANK Insight : Some questions on your COMLEX exam will test unfamiliar concepts. When you come to a question that deals with a subject you are unfamiliar with, do not panic. Just pick an answer and move on.

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Bottom Line: Lidocaine with dilute epinephrine (1:100,000 to 1:400,000) is the preferred local anesthetic mixture to use prior to skin suturing in vessel-rich areas of skin.COMBANK Insight : Because of its vasoconstrictive properties, it was once thought that epinephrine should not be used in skin with limited vascular supply, such as in the terminal extremities (fingers and toes) and the nose. However, studies over the past several years have disproved this.

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Bottom Line: MEN I patients have tumors in their pituitary gland and parathyroid glands, in addition to tumors of the pancreas. In addition, Zollinger-Ellison syndrome may occur sporadically or as part of an autosomal dominant familial syndrome called multiple endocrine neoplasia type 1(MEN 1).

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Bottom Line: Mastitis occurs postpartum and presents with breast pain and redness along with high fever, chills and flulike symptoms. Treatment for mastitis includes dicloxacillin as well as additional options for antibiotics and encouragement of continued breastfeeding or pumping to prevent stasis.

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Bottom Line: Meckel diverticulum is the most common malformation of the intestinal tract characterized by painless bleeding and the rule of 2's. COMBANK Insight : Causes of lower gastrointestinal bleeding in children are highly characteristic and have easily testable associations.

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Bottom Line: Medial epicondylitis is a common overuse syndrome that presents with medial elbow pain exacerbated with resisted wrist flexion as well as wrist pronation.

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Bottom Line: Medical induction of ovulation can lead to multiple ovulations, thereby increasing the risk of multiple-gestation pregnancies.COMBANK Insight : Remember the importance of assessing estrogen production when choosing an agent for the medical induction of pregnancy. Patients who are noted to have adequate production of estrogen should undergo medical therapy with clomiphene citrate, as in the case above. Patients who are found to be hypoestrogenic should undergo treatment with human menopausal gonadotropin (hMG), which is a combination of luteinizing hormone and follicle-stimulating hormone.

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Bottom Line: Most pregnant women have a glucose screening test between 24 and 28 weeks of pregnancy. This is considered the second trimester.COMBANK Insight : OB/GYN is an incredibly high-yield topic. Knowing routine screening tests and their timelines will help you earn easy points on the Comlex. Also, be familiar with quad screens and their results for different trisomies.

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Bottom Line: Nickel dermatitis is a type IV hypersensitivity reaction. Bottom Line: Nickel is the most common metal causing contact dermatitis. It presents as an itchy rash. It is commonly caused by earrings, belts, and watches.COMBANK Insight : A known method for testing this material on board exams involves showing a photo of a child with a rash above the umbilicus. Remember, nickel dermatitis can be caused by belt buckles.

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Bottom Line: Pancreatic cancer has the best prognosis with resectable disease. The gastroduodenal artery can be resected without significant morbidity.COMBANK Insight : Although questions like these often seem too specific and can be frustrating, remember 2 things: First, if you are struggling with it, there are likely many others in the same situation, which the curve will reflect, or the question may be thrown out all together. Second, upper-level questions are a necessary evil to separate high-scoring test-takers. Knowing the answers to questions like these can be what takes you from a good score to a great score.

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Bottom Line: Patients who are hemodynamically unstable, who have severe dyspnea or chest pain with atrial fibrillation, or who have preexcited atrial fibrillation should undergo urgent cardioversion. In stable patients with symptomatic new-onset atrial fibrillation, the rate-control strategy may be considered first to control the ventricular rate. If rate-control treatment does not elicit a response or if echocardiography does not reveal any valvular or functional abnormality of the heart and lack of left atrial thrombus, cardioversion is indicated.

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Bottom Line: Patients who are suffering from acute anterior wall myocardial infarction (MI) often have ECG findings or ST-segment elevation in leads V1-V6, I, and aVL; with reciprocal ST depression in leads II, III, and aVF.COMBANK Insight : Locating MIs based on ECG findings is an important topic. Most of the time the ECG will be shown, however, sometimes you will be given the findings in the stem. Know the different patterns that you would expect to find in new versus old MIs, as well as the leads involved with each location. Atrial fibrillation, MAT, SVT, and AV nodal blocks are also favorite COMLEX questions.

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Bottom Line: Patients with Type 1 diabetes mellitus should begin ophthalmic screening 3-5 years following initial diagnosis of diabetes.COMBANK Insight : The question on the COMLEX exam will need to allow for agreement between all specialty societies. You will not be given a 5-year-old child with diabetes and forced to choose between the AAP guidelines and ADA guidelines (9 vs 10). Just remember that complications of diabetes take time to develop and an immediate eye exam is not necessary in asymptomatic patients with new type 1 diabetes.

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Bottom Line: Patients with significant PAD should be counseled against the use of compression stockings as they may further decrease arterial flow and worsen ischemia. COMBANK Insight : Some questions on your COMLEX exam will test unfamiliar concepts. When you come to a question that deals with a subject you are unfamiliar with, do not panic. Just pick an answer and move on.

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Bottom Line: Pelvic inflammatory disease is a risk factor for ectopic pregnancy.COMBANK Insight : When answering questions that are linked, always keep your diagnosis consistent. Do not stagger your answers, even if you are guessing.

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Bottom Line: Peritoneal signs such as rebound tenderness and guarding are strong indications for surgery in patients with a small bowel obstruction.COMBANK Insight : Knowing when a patient needs emergent surgical intervention is key to success on Level 3.

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Bottom Line: Pneumothorax, or air in the pleural space, may be spontaneous and is classified as either primary (if no underlying lung disease is found on imaging/workup) or secondary (if the patient has known lung disease or another cause is isolated).

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Bottom Line: Polycythemia presents as a ruddy newborn of a diabetic mother.COMBANK Insight : Complications of maternal diabetes and maternal hypertension are common topics. Diabetes is the most common medical complication of pregnancy and hypertension accounts for 15% of maternal deaths.

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Bottom Line: Polyps of the colon should be removed for biopsy when identified by initial colonoscopy.COMBANK Insight : Colon cancer is a highly tested topic because preventative medicine is a core component of osteopathic medicine. Colon cancer screening begins at age 50 because many cases can be found early in the course of the disease, which can decrease morbidity and mortality. Regular screening, beginning at age 50, is the key to preventing colorectal cancer. The US Preventive Services Task Force (USPSTF) recommends screening for colorectal cancer using high-sensitivity fecal occult blood testing, sigmoidoscopy, or colonoscopy beginning at age 50 years and continuing until age 75 years. People at higher risk of developing colorectal cancer should begin screening at a younger age and may need to be tested more frequently. The decision to be screened after age 75 should be made on an individual basis. Screening occurs every 10 years unless otherwise indicated.

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Bottom Line: Primary syphilis is cause by the organism Treponema pallidum and is one of the TORCH infections. It is identified clinically by a painless chancre and confirmed with serologic testing. Treatment is with intramuscular penicillin G.

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Bottom Line: Proximal muscle weakness and Gottron's papules are pathognomonic for dermatomyositis. Dermatomyositis also presents with a heliotrope sign and a shawl sign.COMBANK Insight : Dermatomyositis and polymyositis both have antinuclear antibodies (ANAs) and Anti-Jo-1 antibodies as their immunologic markers. Be sure to be able to distinguish between them. Dermatomyositis presents with skin findings, whereas polymyositis typically does not.

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Bottom Line: Pulmonary embolectomy can be used for pulmonary embolism as a life-saving measure and when heparin therapy is contraindicated.COMBANK Insight : Pulmonary embolism (PE) is a high-yield topic. The COMLEX will present different PE scenarios and testability to identify PE with appropriate treatment. Workup of PE is very high yield. Also, if the question stem has information in it like "the worst headache of my life," you should assume it is there for a reason. It is a test and "key phrases" are key phrases for a reason; please remember that, or you will read too much into these questions. KEEP IT SIMPLE and make it easy on yourself.

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Bottom Line: Radiation exposure less than 50mGy (5 rads) in pregnancy provides negligible risk to the fetus.COMBANK Insight : For medicolegal questions, the ordering physician carries the responsibility. For negligence claims, there must be a duty of care, a breach of that duty, and harm as a result of that breach. In this scenario, there was no breach as the imaging study is not contraindicated in pregnancy (although the physician should have ordered a urine pregnancy test prior). There is also no likely harm to the fetus due to negligible risk below 50mGy radiation dose.

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Bottom Line: Rett syndrome requires early and comprehensive assessment and treatment, utilizing a multidisciplinary approach. Seizures may occur in Rett syndrome and are treated with a range of modalities.COMBANK Insight : Level 3 moves past questions regarding basic science principles and addresses diagnosis, management, and pathophysiology. If this were a Level 1 question, you might expect to be asked to identify the gene mutation most commonly responsible for this syndrome.

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Bottom Line: Rouleaux formation is an important and classic sign of increased serum proteins and typically indicates Waldenström macroglobulinemia or multiple myeloma. Waldenström macroglobulinemia is a condition characterized by the presence of a high level of a macroglobulin (immunoglobulin M [IgM]), elevated serum viscosity, and the presence of a lymphoplasmacytic infiltrate in the bone marrow.

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Bottom Line: Shortness of breath is a symptom that carries a broad differential diagnosis. When a patient presents with this symptom, obtaining a thoughtful history and performing a careful physical exam are crucial to not missing critical diagnoses. This patient presents with signs and symptoms concerning for possible metabolic cause of shortness of breath, however it is important to rule out other common disease processes as well.COMBANK Insight : Take into consideration vital signs, physical exam, and history when forming a differential diagnosis. Do not forget to consider metabolic causes of shortness of breath.

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Bottom Line: Small bowel obstruction typically presents with nonspecific symptoms of abdominal pain and distension, nausea, and vomiting. An abdominal radiograph series is the first step in the workup, and findings will include air-filled dilated loops of small bowel without much air in the rectosigmoid. If the diagnosis is equivocal, a CT examination of the abdomen and pelvis is the next step. Treatment is conservative with bowel decompression or surgical correction.

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Bottom Line: Suspect N. gonorrhoeae as the likely organism causing pharyngitis in young patients with a sexual history and joint pain.COMBANK Insight : Treat N. gonorrhoeae pharyngitis with ceftriaxone 250 mg IM as a single dose, plus azithromycin 1 g orally or doxycycline 100 mg orally twice daily for 7 days.

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Bottom Line: Suspect carcinoid syndrome in a patient with flushing, diarrhea, and bronchospasm with elevated 5-HIAA. The most common location of a carcinoid tumor is the terminal ileum; the most common location of carcinoid malignancy is the appendix.COMBANK Insight : Clinical symptoms can arise from the primary tumor, from the sequelae of metastatic disease, or from the carcinoid syndrome. Many intestinal carcinoids are small and asymptomatic. They are found incidentally or at autopsy.

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Bottom Line: Suspect cocaine intoxication in patients who present with symptoms such as tachycardia, diaphoresis, hypertension, and other sympathetic findings. Amphetamine toxicity also presents with similar findings; however, there is also psychosis, which differentiates it from cocaine toxicity.COMBANK Insight : Substance intoxication is extremely high-yield on COMLEX Level 3! You are likely to see at least a handful of questions on this topic. Knowledge of the differing presentations, physical findings, complications (such as cardiac-related issues with cocaine), and treatment plans will take you a long way on these questions.

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Bottom Line: Suspect seasonal affective disorder in any patient who presents with patterned symptoms of depression in the winter months with resolution in the summer.COMBANK Insight : Be prepared for short question stems with slight clues leading you toward a correct diagnosis. Unlike the USMLE, the COMLEX rarely includes excessive details about a case. When differentiating psychiatric diagnoses, be sure to pick up on any specific points that may lead you toward a correct diagnosis. Most of the time, the time frame will allow you to differentiate between subtypes of depression. In this stem question, it is clear that the patient's symptoms are occurring in the winter months, and this information points to the diagnosis of seasonal affective disorder. This will hopefully allow you to get this question correct, along with the remaining 2 that will follow.

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Bottom Line: T. vaginalis is diagnosed by a saline wet mount, which reveals flagellated, motile trichomonas. Treatment is with metronidazole.

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Bottom Line: Tetracyclines can cause permanent discoloration of teeth in children and adults.

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Bottom Line: The Thomas test is a useful tool in the evaluation hip flexor tightness, which can be seen in Psoas syndrome.COMBANK Insight : Physical exam findings can often lead to a specific diagnosis. When answering linked questions, make sure your answers coincide with one another.

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Bottom Line: The common fibular nerve, innervated by L4-S2 supplies sensory innervation to the anterior lateral leg and motor innervation to the anterior lower leg, specifically those muscles responsible for dorsiflexion.

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Bottom Line: The diagnosis of an anterior shoulder dislocation on an x-ray should be an easy one to make. Almost all shoulder dislocations are anterior; the typical radiographic findings are anterior and inferior dislocation in relation to the glenoid fossa. Posterior dislocations often look normal on a frontal chest radiograph, and dedicated shoulder radiographs should be obtained to evaluate for it.

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Bottom Line: The diagnosis of hemochromatosis is supported by labs that show an increased serum iron level, increased percent saturation of iron, increased ferritin, and decreased serum transferrin levels.

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Bottom Line: The globe is a hollow structure filled with fluid, encompassed within 3 layers: the sclera, the choroid, and the retina. The sclera is the outermost "white part" of the eye. The choroid is the middle vascular layer. The retina is the innermost layer, within which the photoreceptor cells are contained. Replace the word "eyeball" in your mind with the word "globe." Think of the inner structures of the globe as the organs, the "viscera," with the sclera as their outermost encasing, almost like the skin. This will help you understand the common surgical procedures

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Bottom Line: The goal in tertiary prevention involves interventions to prevent further deterioration or complications of a disease process.

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Bottom Line: The pedal pump can be a valuable tool for augmenting thoracoabdominal pressure gradients but is contraindicated in patients with deep venous thrombosis or fractures to the lower extremities and in patients who have recently undergone surgery to the abdomen.COMBANK Insight : Postsurgical complications can be decreased by using certain osteopathic manipulative medicine (OMM) techniques. The more likely an OMM treatment is to be helpful clinically, the more likely it will be on your Level 3 exam.

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Bottom Line: The transferrin saturation is calculated by dividing the serum iron by the transferrin level, and a high transferrin saturation with an elevated ferritin level increases the likelihood of hemochromatosis.

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Bottom Line: Torsades de pointes is a ventricular tachycardia with a characteristic twisting of the QRS waves. It is associated with long QT syndrome.COMBANK Insight : Be familiar with the classic ECG findings for all the arrhythmias. You will most likely be expected to identify the underlying pathophysiology and the corresponding treatment when given an ECG.

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Bottom Line: Transient ischemic attack presents with transient focal neurologic symptoms. It can be caused by an embolus from the heart that gets dislodged from chronic atrial fibrillation.

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Bottom Line: Transient monocular vision loss in a patient with atrial fibrillation is concerning for cardioembolic phenomenon and should be worked up with an ECG and echocardiogram. Most of these patients will additionally require anticoagulation to prevent future stroke.COMBANK Insight : Common clinical practice does not always follow guidelines. For your exam, you will be tested based on current guidelines and best practice, not what you see being done. CT of the brain has no role in the workup of transient vision loss.

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Bottom Line: Transthoracic echocardiography (TTE) with bubble study is the inital test of choice when trying to establish the presence of a PFO. It is generally performed with agitated saline as contrast. During the test, the patient will be asked to valsalva, which transiently increases right-sided pressures and may cause a shunt across the open septum. If bubbles are seen in the left atrium almost immediately, this is a positive test. TTE may not always reveal a PFO, making a trans-esophageal echocardiogram a better test, however, due to increased complication rates and higher risks, this is rarely performed unless clinical suspicion is extremely high and the TTE is negative.

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Bottom Line: Uncomplicated diverticulitis can be managed conservatively with IV antibiotics and NPO status.COMBANK Insight : The absence of leukocytosis does not rule out diverticulitis, as 20%-40% of patients have a normal white blood cell count.

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Bottom Line: When a Pap smear result returns with evidence of atypical glandular cells, a colposcopy with endometrial curettage must be performed due to the increased risk of cervical neoplasia.COMBANK Insight : Many of the pathologies can sound similar. Be careful to identify the differences in treatment for each one.

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Bottom Line: While preparing for delivery, administration of betamethasone may be considered in pregnant women between 34 0/7 weeks and 36 6/7 weeks of gestation who are at risk of preterm birth within 7 days. A Cochrane review showed that the use of steroids had an overall reduction in neonatal death, respiratory distress syndrome, cerebroventricular haemorrhage, necrotising enterocolitis, respiratory support, intensive care and systemic infections in the first 48 hours of life.

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Bottom Line: With an avulsed tooth, do not touch the root and only handle the tooth by the crown. Gentle debridement with saline is acceptable, and reimplantation should be attempted. Consult a dental or oral maxillofacial surgeon for splinting and further evaluation. If the tooth was absent for less than 20 minutes, the prognosis is better. All periodontal ligament cells die if the tooth is out of the socket longer than 60 minutes.

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Bowen's disease often presents with a single asymptomatic, slowly enlarging, erythematous, scaly patch or plaque, most commonly present on sun-exposed areas. Early skin manifestations may be subtle and overlap with clinical features seen in many benign conditions such as tinea corporis, nummular eczema, and psoriasis.

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By 6 to 8 months, a child should be able to sit unassisted, transfer objects, babble, and exhibit stranger anxiety.

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By definition this patient has heart failure with reduced ejection fraction and you must have chosen that answer to get this question correct. He more likely has a non-ischemic cardiomyopathy (NICM) from chronic hypertension than an ischemic cardiomyopathy (ICM) as he has no history of coronary artery disease or angina, however, it is possible to have a silent ICM given his age and in general ICM is a more common cause of systolic dysfunction, so choosing either of those would not be completely incorrect and both were listed as neutral. The remainder of the answers were wrong and would have lost you points. Systolic dysfunction is generally defined as an LVEF less than 40% and when accompanied by the clinical signs and symptoms of heart failure (orthopnea, paroxysmal nocturnal dyspnea, fatigue, edema, increased jugular venous pressure, pulmonary congestion among others) is now called heart failure with reduced ejection fraction or HFrEF. The most common cause of systolic failure is ischemic heart disease which is called ischemic cardiomyopathy (ICM). If there are no signs of obstructive coronary artery disease on heart catheterization, then the cardiac failure is classified as non-ischemic cardiomyopathy (NICM) and other causes need to be considered such as alcohol abuse, persistent tachycardia, hemochromatosis, etc.If the patient were to have a normal ejection fraction on transthoracic echocardiogram with signs and symptoms of heart failure, then they would be labeled with heart failure with preserved ejection fraction (HFpEF). This is most commonly caused by long-standing hypertension which causes hypertrophy and stiffening of the left ventricle with reduced cardiac filling. Not all patients with diastolic dysfunction on echocardiogram have the symptoms of heart failure and should not be diagnosed as such. Diastolic dysfunction is an echocardiographic diagnosis while heart failure is a clinical diagnosis based on the Framingham criteria.

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Liver biopsy is the gold standard for diagnosing Wilson disease; however, it is most often used when patients present with only hepatic symptoms and do not yet have neurologic symptoms and Kayser-Fleischer rings. It is more invasive and time-consuming than a ceruloplasmin level; hence, a ceruloplasmin level is the next best step in a neurologically symptomatic patient.

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By the beginning of the second trimester, fetal urine begins to enter the amniotic sac. Therefore, disorders related to the fetal renal/urinary system begin to play a prominent role in the etiology of oligohydramnios. The common etiologies associated with oligohydramnios are renal (65%), multiple (12%), aneuploidy (8%), central nervous system (5%), skeletal system (4%), cardiovascular system (3%), and other (4%). Renal anomalies are the most common anomaly associated with oligohydramnios. Another common cause of oligohydramnios is rupture of membranes. In this situation, as soon as oligohydramnios is diagnosed on ultrasound, one should also evaluate the fetal kidneys during ultrasonic exam. Treatment is based on the underlying abnormality; fetal amnioinfusion can be performed during labor to prevent cord compression, the feared complication.

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C. trachomatis is the most common cause of pelvic inflammatory disease. It causes cervical friability and a mucopurulent cervical discharge. Patients can be asymptomatic or can present with dyspareunia, bleeding after intercourse, or dysuria. It is typically treated with doxycycline or azithromycin. If the patient is pregnant, she can be treated with erythromycin. If compliance is an issue, azithromycin is a better choice, as it is given in a single dose. Patients with this infection do not also need to be treated for a Neisseria gonorrhea infection. However, patients with gonorrhea should also be treated for chlamydia.

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COMBANK Insight : There are usually a significant number of rheumatologic cases dealing with myopathies on COMLEX 3. Know how to differentiate these disorders based on their characteristic features. You'll typically be given a multi-step case that involves making a correct diagnosis, identifying characteristic findings/laboratory values/etc, and then choosing the correct treatment plan. Make sure you know the role of OMM in each of these disorders, especially fibromyalgia.

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COMBANK Insight : Trauma is the leading cause of maternal death, accounting for up to 46% of cases. Fetal death, however, is a more common occurrence than maternal death. To avoid compression of the inferior vena cava in a patient who is in her 2nd or 3rd trimester, the left lateral decubitus position should be used.

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Candida esophagitis is usually manifested clinically by dysphagia and/or odynophagia in a patient with one or more predisposing factors for the condition. Symptoms vary in severity, ranging from mild difficulty in swallowing to such intense odynophagia that the patient is unable to eat or swallow saliva. Other patients may present with chest pain or gastrointestinal (GI) tract bleeding. Occasionally, patients are asymptomatic.

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Carvedilol is a beta-blocker that, along with metoprolol succinate and bisoprolol, has been proven to decrease mortality in patients with systolic heart failure. Systolic heart failure leads to an overactivation of the sympathetic nervous system generally in response to low blood pressure and decreased cardiac output. Chronic sympathetic activation causes remodeling of the myocardium eventually leading to decreased cardiac output. Beta blockers slow heart rate allowing for increased cardiac filling and decreased myocardial oxygen demand. Beta blockers that have been approved for this purpose include carvedilol, long-acting metoprolol (succinate), and bisoprolol. These medications should be started at low doses and titrated to a target heart rate of 60/min. The patient's heart failure should be stable for at least 2 weeks before the medication is increased as sudden, high-dose beta blocker use can precipitate worsening heart failure by decreasing cardiac output due to sudden drops in heart rate before compensation has occurred. Many patients can tolerate high doses when the dose is increased slowly.

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Cephalexin is a first generation cephalosporin used to treat cellulitis. If the patient presented with a fever or elevated white blood cell count in addition to erythema and fluctuance surrounding the lesion, then cellulitis should be considered. Infection can complicate a venous ulcer but there is not enough evidence for that in this vignette.

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Chelating agents such as succimer, penicillamine or dimercaprol can be used to treat heavy metal poisoning with lead, mercury or arsenic.

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Cheyne-Stokes respirations describe an abnormal breathing pattern characterized by cycles of apnea followed by hyperpnea. This causes waxing and waning of the tidal volume. 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. In these patients, it is most commonly seen in sleep, when breathing is completely the result of neural reflex mediated by levels of carbon dioxide and oxygen. This breathing pattern affects quality of life and survival. Cheyne-Stokes respirations can also be seen in patients suffering from stroke, traumatic brain injury, brain tumors, and carbon monoxide poisoning. Treatment is a reversal of the underlying cause.

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Chickpeas are a good source of iron which does not need to be avoided prior to or during pregnancy. In fact, iron supplementation is recommended once pregnancy has occurred. Starting at the first prenatal visit, pregnant women should be placed on 30 mg/day of elemental iron.

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Chronic constipation is also a common side effect of many medications such as opiates, antipsychotics, antihistamines, antidepressants, iron supplementation, antihypertensive agents, calcium channel blockers, and 5HT3 antagonists.The patient has a significant amount of stool present in the rectal vault, unlike patients suffering from colonic inertia or irritable bowel syndrome, who have little or no stool remaining in the rectum between defecations. During examination, pelvic floor dysfunction manifests with contraction of the upper segment of the sphincter during straining. This is noted by the failure of descent of the examining finger during sphincter contraction.

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Colonic pseudo-obstruction or Ogilvie's syndrome is a dilated colon that appears to be obstructed with no underlying mechanical obstruction. Although the etiology is broad, this condition is most commonly caused by medications and electrolyte abnormalities. Other causes of Ogilvie's syndrome include neuromuscular disorders, hypothyroidism, malnutrition, and age. Due to the risk of perforation, when colonic pseudo-obstruction is suspected, management mandates urgent nasogastric decompression, intravenous fluid resuscitation, metabolic panel, and abdominal radiography. Temporary rectal tubes and/or colonoscopy may be necessary to permit colonic decompression. The use of neostigmine in a patient without contraindications is likely to resolve the syndrome in unresponsive cases. Surgery is only required when ischemia, necrosis, or perforation occurs.

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Colorectal cancer is the third most common malignancy in the world, of which 95% are adenocarcinoma. Other than genetic risk factors, a high-fat, low-fiber diet, inflammatory bowel disease, previous radiation, and adenomatous polyps are all risk factors for colorectal cancer. The management of presumed colorectal cancer includes thorough history and physical; laboratory evaluation, particularly carcinoembryonic antigen (CEA) level and liver function tests; chest radiograph; and abdominal/pelvic computed tomography (CT) scan.When a polyp or mass is detected incidentally on a screening colonoscopy, multiple biopsies or polypectomy is necessary for pathologic evaluation. The decision about how to perform a polypectomy is often made during colonoscopy when a polyp is detected. A general rule is that all potential adenomas should be removed. The endoscopic appearance of a polyp is often not necessarily a good indicator of its histologic nature. Although as many as 70% of diminutive polyps (<5 mm) may be adenomas, the risk of any particular polyp containing malignancy increases with the size of the polyp. The method chosen for polypectomy is often related to the appearance and size of the polyp. Polyps are usually described as being pedunculated, sessile, or flat. The risk of a polyp 2 cm in size or larger being malignant is greater than 10%.General screening guidelines form the American Cancer Society indicate the following:Tests that find polyps and cancer:Flexible sigmoidoscopy every 5 years*Colonoscopy every 10 yearsDouble-contrast barium enema every 5 years*CT colonography (virtual colonoscopy) every 5 years*Tests that mainly find cancer:Guaiac-based fecal occult blood test (gFOBT) every year*,**Fecal immunochemical test (FIT) every year*,**Stool DNA test (sDNA) every 3 years*KEY*Colonoscopy should be done if test results are positive.**Highly sensitive versions of these tests should be used with the take-home multiple sample method. An FOBT or FIT done during a digital rectal exam in the doctor's office is not adequate for screening.Once a patient is labeled as having an increased risk, then the recommendations change:

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Compartment syndrome is a surgical emergency that requires immediate surgical decompression. Failure to perform surgical intervention may result in irreversible muscle necrosis. Therefore, whenever compartment syndrome is suspected, immediate surgical consultation should be the initial step in management. This is one of the rare circumstances where surgery is the immediate first-line therapy. When diagnosing compartment syndrome, remember the 5 P's: pallor, paresthesias, pulselessness, paralysis, and pain with passive extension of the affected limb.

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Contact dermatitis is not characteristically associated with celiac disease. Contact dermatitis is a type of skin inflammation (dermatitis). It results from exposure to allergens (allergic contact dermatitis) or irritants (irritant contact dermatitis).

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Copper is a trace mineral found largely within vegetables, grains, and legumes. Absorption is through the small intestine and stomach. Two key regulators are required, and mutations are associated with 2 disease states. Menkes P-type ATPase (ATP7A) is an enzyme that allows secretory efflux from enterocytes and other cells. Mutations in this gene result in Menkes disease, which is characterized by "kinky hair" (pili torti), hypopigmentation, bony abnormalities, and progressive neurologic deterioration. After ATP7A allows copper efflux, it is transported to the liver where it is incorporated into ceruloplasmin. Wilson P-type ATPase (ATP7B) is responsible for copper trafficking through ceruloplasmin and mutations in this result in Wilson disease. Wilson disease has multiple clinical features secondary to copper ACCUMULATION, not a deficiency. These findings include cardiac dysfunction, liver cirrhosis, and pancreatic dysfunction. While the latter may result in new glucose intolerance, it is likely to occur over the course of years and is secondary to excess copper, not deficiency.

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Corticosteroids are often a part of the treatment for MG flares. Paradoxical worsening may occur in half of all patients with MG, and myasthenia crisis occurs in up to 18% of these patients. Therefore, among patients with MG, corticosteroid administration should always be administered in the hospital setting. Because of this severe side effect, intravenous immunoglobulin (IVIg) and plasmapharesis are often used as first-line therapies, and preparation for intubation needs to be performed when administering corticosteroids in severe exacerbations.

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Corticosteroids are the mainstay treatment for dermatomyositis, and prednisone is commonly administered as an initial medication. This patient is presenting with muscular manifestations of the disease, which tend to improve dramatically following treatment with corticosteroid therapy. Treatment begins with high dose corticosteroids which are tapered, generally over a long period of time. Disease modifying agents such as methotrexate can be used for refractory symptoms. In addition to management with corticosteroids, workup for a potential underlying malignancy should be completed, as dermatomyositis may present as a paraneoplastic process.

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Cutaneous (skin) anthrax is treated with antibiotics taken by mouth, usually for 7 to 10 days. Doxycycline and ciprofloxacin are most often used.

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Cyanide toxicity most commonly occurs when toxic fumes are produced during fires. Industrial sources include metal cleaning, fumigation, electroplating, and photo processing. Amyl nitrate converts hemoglobin into methemoglobin, which binds to cyanide. Other drugs to treat cyanide poisoning include sodium nitrate and thiosulfate, which are found in cyanide antidote kits. Thiosulfate works more slowly than nitrates and should be used in conjunction. Carbon monoxide poisoning may also occur during fire exposures and should be treated with oxygen.

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Damage to the vagus nerve would likely result in aphonia as there would be bilateral vocal cord paralysis, along with other symptoms related to vagal dysfunction. The recurrent laryngeal nerve is a branch of the vagus nerve.

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Depression is commonly associated with panic disorder. Up to one-third of panic disorder cases are associated with depression. Patients begin to have a fear of the panic attacks, which can lead to phobias (particularly agoraphobia, or fear of being unable to escape a situation) and/or depression. The reverse is also true, in that some proportion of patients will have depression first and then develop panic disorder.

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Diagnosis of depression requires depressed mood or anhedonia in addition to 5 or more signs or symptoms from the mnemonic SIG E CAPS (sleep, interest, guilt, energy, concentration, appetite, psychomotor agitation, suicidal ideation) occurring for at least 2 weeks. Dysregulation of serotonin is associated with depression.

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Dicloxacillin and cephalexin are the preferred first-line therapies for nonbullous impetigo. This infection is most commonly caused by β-hemolyticStreptococcus or Staphylococcus aureus, with only around 1% of cases being identified as methicillin-resistant S aureus (MRSA). The Infectious Diseases Society of America (IDSA) has clear recommendations on therapy, and multiple sources agree with use of topical mupirocin for limited infections and empiric treatment covering both Streptococcus and Staphylococcus species. If culture determines Streptococcus species as causing disease, then oral penicillin is a reasonable alternative. Because this patient has extensive skin involvement and culture has not been performed, oral dicloxacillin, an antistaphylococcal penicillin, is indicated for empiric treatment

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Diverticulitis is caused by increased intraluminal pressure or inspissated food particles, leading to perforation of the colonic diverticula that causes focal necrosis and inflammation. It commonly presents in elderly patients with fever, elevated white blood cell count, and left-lower-quadrant pain. If there is evidence of severe, generalized abdominal pain and guarding, there would be a concern for perforation, and a stat upright chest radiograph should be ordered. Diagnosis is made with abdominal and pelvic CT scan with oral and IV contrast, which would reveal bowel-wall thickening, fat stranding, and/or abscess formation. Management of uncomplicated diverticulitis includes making the patient nothing-by-mouth (NPO) status, with IV fluid hydration, in addition to either a fluoroquinolone plus metronidazole antibiotics or a third-generation cephalosporin plus metronidazole. In this case, there is no indication of perforation (unstable vital signs, rebound tenderness, or guarding), thus conservative management should be tried initially. If there is evidence of perforation or obstruction, broad-spectrum antibiotics should be started, followed by surgical intervention. If abscess is found on imaging, CT-guided percutaneous drainage is indicated.

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Duodenal atresia refers to the congenital absence or complete closure of a portion of the duodenal lumen. The most common presentation is bilious emesis, which begins several hours following the initial post-delivery feeding. Radiographic evidence of this condition is characterized by the finding known as the "double bubble" sign on abdominal radiography. This occurs due to the presence of gaseous distention in the gastric and duodenal portions of the GI tract. Duodenal atresia results from failure of the duodenal lumen to recanalize during the 8th to 10th weeks of gestation. Polyhydramnios occurs in approximately half of all cases due to impaired absorption of amniotic fluid by the fetal intestines. Malrotation of the intestines and congenital heart disease are also frequently present.

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E. coli typically causes traveler's diarrhea, which is watery. Bloody diarrhea may occur after eating a contaminated hamburger (hemolytic uremic syndrome).

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E: Primary sclerosing cholangitis (PSC) results in inflammation and fibrosis of the biliary tree. It has a classic "beads on a string" appearance on imaging. It does not result in fusiform dilation of the extrahepatic bile duct. PSC has a classic association with inflammatory bowel disease, and most patients who present with PSC are asymptomatic at the time of diagnosis. Symptoms that do occur commonly include jaundice and pruritus. Pain from this condition is rare and felt to more often represent episodic cholangitis.

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EKG findings are an important part of the evaluation of most cardiac conditions and are heavily tested. The EKG findings in PE almost all relate to the clot burden causing increased pulmonary artery pressures and right ventricular strain or failure. Some known findings include sinus tachycardia, new RBBB, and S1Q3T3 pattern, however, patients may have signs of ischemia or strain in any distribution and could have nonspecific ST and T wave changes. New onset atrial fibrillation is also possible, as well as bradycardia.Sinus tachycardia is the most common manifestation of PE. More so than the S1Q3T3 which was thought to be exceedingly rare, but has been increasingly recognized and is associated with right ventricular strain. Sinus tachycardia is a sympathetic response meant to increase cardiac output and systemic pressures. The RSR' pattern in leads V1 and V2 is indicative of a right bundle branch block and can be caused by an acute PE. The sudden development of a new RBBB is very concerning in the setting of dyspnea and suspected PE as it can be indicative of right heart failure. A new RBBB is due to stretching of the right ventricle and obstruction of the right bundle due to changes in ventricular morphology.

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Early (1-3 hours) (also known as hyperacute phase): Within the first few hours a number of signs are visible depending on the site of occlusion and the presence of collateral flow. Early features include the loss of grey-white matter differentiation, and hypoattenuation of deep nuclei such as the lentiform nucleus. These changes seen as early as 1 hour after occlusion and become visible in 75% of patients at 3 hours. Next, cortical hypodensity with associated parenchymal swelling with resultant gyral effacement becomes visible.First week: With time the hypo-attenuation and swelling become more marked resulting in significant mass effect. This is a major cause of secondary damage in large infarcts. Second to third week: As time goes on the swelling starts to subside and small amounts of cortical petechial hemorrhages results in elevation of the attenuation of the cortex. This is known as the CT fogging phenomenon. Imaging a stroke at this time can be misleading as the affected cortex will appear near normal. Months: The residual swelling passes, and gliosis sets in eventually appearing as a region of low density with negative mass effect. Cortical mineralization can also sometimes be seen appearing hyperdense.

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Edrophonium is an acetylcholinesterase inhibitor with rapid onset and short duration of action. This thereby increases acetylcholine in the neuromuscular junction, leading to improvement with incremental increases in administration. Ptosis and ocular muscle weakness may improve with this test. This test has good sensitivity but many false-positive and false-negative results, thus limiting its usefulness. Additionally, patients may experience cholinergic side effects and severe bradycardia, which has also limited its use. Production of edrophonium was discontinued in 2008.

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Electrocardiograms (ECGs) are useful in anxiety attacks for evaluating possible tachydysrhythmia, and screening for adverse medication effects such as QT prolongation. The history remains the best tool available in the evaluation of anxiety. Laboratory tests are rarely needed to affirm the diagnosis. Even if anxiety is suspected, serious medical conditions should be ruled out.

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Elejalde syndrome presents with silver hair but their immune systems are fully functional. They do, however, often have severe neurological sequelae including seizures and mental retardation. Also of note is that these patients often have very bronze-appearing tans.

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Elevated LDH suggests an acute hemolytic reaction. The symptoms include fever, chills, and hypotension. The presence of wheezing and a skin rash (urticaria) makes anaphylaxis the more likely diagnosis.

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Elevated direct bilirubin suggests biliary obstruction. Elevated indirect bilirubin suggests hemolysis.

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Lorazepam is the first medication that should be used to treat acute seizures or suspected status epilepticus.COMBANK Insight : A patient who does not recover from the post-ictal state before seizing again is highly suspicious for status epilepticus and needs to be treated accordingly. You can and should give multiple doses of lorazepam if necessary.

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Epistaxis that is prolonged and difficult to control is most likely to be a posterior bleed. Posterior bleeds are associated with the sphenopalatine artery, which arises from the maxillary artery. If medical treatment fails, an otolaryngologist may choose to ligate the maxillary artery because this procedure has a higher success rate than ligation of the external carotid artery. Anterior nose bleeds, on the other hand, nearly always arise from the Kiesselbach plexus. The Kiesselbach plexus is an anastomotic network of vessels on the anterior portion of the nasal septum.Causes of posterior nose bleeds may vary. Risk factors include anticoagulation, alcohol, nasal allergy medications, familial blood dyscrasias (eg, von Willebrand disease), hereditary hemorrhagic telangiectasia, aneurysms of the carotid artery, and nasal neoplasms. Hypertension and aspirin use may also increase risk. Anterior nosebleeds may be caused by nose picking, low moisture content in the air, foreign body, and chronic excoriation.

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Erb-Duchenne palsy is most commonly caused by traumatic stretching of the brachial plexus during childbirth. Shoulder dystocia is the major complication that leads to this injury. The most commonly involved nerve roots are C5 and C6, and the most common nerves are the suprascapular nerve, musculocutaneous nerve, and the axillary nerve. Other signs of Erb palsy include loss of sensation in the arm and paralysis and atrophy of the deltoid, biceps, and brachialis muscles. The position of the limb, under such conditions, is characteristic: the arm hangs by the side and is rotated medially; the forearm is extended and pronated. The arm cannot be raised from the side; all power of flexion of the elbow is lost, as is also supination of the forearm. The resulting biceps damage is the main cause of this classic physical position, commonly called "waiter's tip." If the injury occurs at an age early enough to affect development, it often leaves the patient with stunted growth in the affected arm with everything from the shoulder through to the fingertips smaller than the unaffected arm. This also leaves the patient with impaired muscular, nervous, and circulatory development. The lack of muscular development leads to the arm being much weaker than the unaffected one, and less articulate, with many patients unable to lift the arm above shoulder height unaided, as well as leaving many with an elbow contracture.The lack of development to the circulatory system can leave the arm with almost no ability to regulate its temperature, which often proves problematic during winter months when it would need to be closely monitored to ensure that the temperature of the arm was not dropping too far below that of the rest of the body. The damage to the circulatory system also leaves the arm with another problem. It reduces the healing ability of the skin, so that skin damage takes far longer than usual to heal, and infections in the arm can be quite common if cuts are not sterilized as soon as possible.

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Erythema infectiosum is caused by parvovirus B19 and is characterized by a "slapped cheek" rash in addition to a erythematous, pruritic, maculopapular rash that starts on the arms and spreads to the trunk and legs.

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Erythema infectiousum (fifth disease) is caused by parvovirus B19, and presents with a "slapped-cheek" rash which appears simultaneously with low-grade fever and malaise. In adults, this virus may cause arthralgias.

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Eszopiclone is a GABAA agonist that is indicated for the short-term treatment (6 to 12 months) of primary insomnia. It should only be used if the patient can devote 8 or more hours to sleep.

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Extension of the lesion does not occur. This lesion is a capillary hemangioma, a hamartoma of the capillaries, which typically presents shortly after birth, peaks in size by 1 year of age, and then slowly regresses with 75% of lesions resolving by 4 to 5 years of age.

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Factor VIII concentrate is a treatment for von Willebrand disease and will not be useful in this patient.

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Fiberoptic laryngoscopy can be used to identify both unilateral and bilateral vocal cord paralysis. The patient in the above case is likely suffering from right recurrent laryngeal nerve paralysis secondary to nerve injury during thyroidectomy. Laryngeal configuration and mobility are best evaluated using fiberoptic laryngoscopy or rigid-tube laryngoscopy, which provide magnification and recording of the image for further study. Laryngeal stroboscopy can also be used for a detailed evaluation of vocal fold vibration and is especially useful for postoperative evaluation. The remaining studies provide little information regarding the injury and extent of injury to the true vocal cords.

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Fitz-Hugh-Curtis (FHC) Syndrome was originally described in the setting of Neisseria gonorrhoeae infection, however, more recent studies have shown that Chlamydia trachomatis is a much more common etiology of this condition. Patients presenting with complaints consistent with pelvic inflammatory disease (PID) and suspected FHC should generally be treated for both organisms and may require broad spectrum antibiotics depending on complications. The goals of treatment are to relieve symptoms, cure the infection, and help prevent infertility or ectopic pregnancy which are commonly associated with causes of fallopian tube inflammation or scarring such as PID.PID refers to acute infection of the upper genital tract in women. This includes the uterus, fallopian tubes, and ovaries and often presents with fever, abdominal pain, and vaginal discharge. These infections can often develop abscesses or expand into adjacent structures and are associated with the development of infertility and ectopic pregnancy which can be devastating. This disease is most common in sexually active women. The infection is almost always considered to be polymicrobial and causative organisms include Chlamydia trachomatis and Neisseria gonorrhoeae. Other vaginal flora such as anaerobic organisms, enteric gram-negative rods, streptococci, genital mycoplasma, and Gardnerella vaginalis can be isolated from infected material, however, it is unclear what role they play in the development of infection and whether or not women need empiric coverage for these organisms. Many patients with mild or moderate PID do not receive empiric anaerobic coverage and do quite well leading many physicians to wonder whether these organisms are innocent bystanders. Those with severe disease requiring hospitalization are generally treated with broad spectrum antibiotics covering the above organisms due to severity of illness.

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Fluphenazine is a phenothiazine antipsychotic. Phenothiazines are contraindicated in tricyclic antidepressant overdose, as they may exacerbate the symptoms.

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Folate supplementation with 4 mg/day should be used by women with a history of NTD in prior pregnancy. It should be initiated 1 month prior to conception and maintained during the first trimester.

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Folic acid dosage should be 0.4 mg/day or 4 mg/day for women with a history of neural tube defects in prior pregnancies.

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For the Yergason test, the patient flexes the elbow to 90º while the examiner holds the elbow with one hand and the wrist with the other hand. The examiner pulls downward on the patient's elbow and externally rotates the forearm as the patient resists this movement. If the patient has pain, this means the biceps tendon is injured.

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Fresh frozen plasma and cryoprecipitate are treatments for disseminated intravascular coagulation and have no role in treatment of ITP.

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Frontotemporal dementia is characterized by cognitive decline with significant alterations in personality as the predominant symptom. Patients generally become sexually disinhibited, demonstrate impulsivity, and lose their ability to recognize social cues. This is due to predominant damage to the frontal cortex. Families may notice the personality changes before there are signs of significant cognitive decline.

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G. vaginalis presents with thin, white, fishy, musky, ivory odor. A saline wet mount shows clue cells, which are epithelial cells with multiple attached bacteria. A KOH wet mount will reveal a fishy odor, which is evidenced during a positive whiff test. Vaginal pH > 4.5. Treatment is with metronidazole.

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Giant cell arteritis, or temporal arteritis, is a large and medium-sized vessel arteritis that typically affects patients over 50 years of age. Symptoms include weight loss, headache, fatigue, fevers, joint and muscle pain, jaw claudication, scalp tenderness, and acute vision loss. Systemic complications include myocardial infarcts, aortic dissections, and cerebrovascular events. Ophthalmic consequences involve an arteritic anterior ischemic optic neuropathy secondary to occlusion of the short posterior ciliary arteries. Definitive diagnosis is confirmed by temporal artery biopsy of at least 2 to 3 cm. Suspicion of this disease should prompt immediate administration of high-dose corticosteroids to prevent blindness and neurologic evaluation in addition to checking an erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and complete blood count. An increased platelet count, along with elevated ESR and CRP, can be a clinical indicator of active disease. Treatment includes immediate intravenous methylprednisolone at a divided dose of 1 g/d for 3 to 5 days with a switch to prednisone tapered over 3 to 12 months. Fluorescein angiography will also show delayed filling of the optic disc and choroidal circulation.

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Given the scenario, the most appropriate action for the physician to take is to recommend that the patient see someone else for her psychiatric care. Although it is recommended that all physicians avoid intimate encounters with both present and former patients, this behavior is absolutely prohibited for psychiatrists.

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Giving aspirin to a child under 15 years of age with a fever can cause Reye syndrome. The question stem usually involves a child with chickenpox, influenza, or an upper respiratory infection that is treated with aspirin. Symptoms include vomiting and delirium, which may lead to coma. Reye syndrome causes encephalopathy and/or liver failure. This can occur after giving aspirin to patients with influenza or varicella. Aspirin should only be given to children in the presence of Kawasaki disease. Salicylate toxicity can cause vertigo, respiratory alkalosis, tinnitus, metabolic acidosis, and respiratory alkalosis.

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Glioblastoma multiforme (GBM) is an aggressive grade IV astrocytoma and is characterized by its butterfly appearance as it crosses the midline. It is a primary neoplasm of the brain characterized by necrosis and extensive vascularity. It is the most common of the primary brain neoplasms and is seen in middle-aged and older patients. It may present with focal neurologic deficits and seizure, and the prognosis is poor. The appearance of a GBM is quite different than a meningioma. The tumor will be ill-defined, intra-axial, and cause extensive mass effect and edema. Treatment consists of tumor debulking, followed by radiation therapy.

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Graves Disease has a classic appearance and should be a consideration when there is neck swelling with associated symptoms.

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Griscelli syndrome is a logical choice in this question although these children tend to be far more ill and require bone marrow transplant very early in life. They do share the albinism characteristic of hair with a "silvery sheen" with Chediak-Higashi. The major difference in Griscelli is the presence of severe neurologic symptoms that present at or shortly after birth and remain stable. These symptoms may include hypotonia, peripheral facial palsy, spasticity and seizures.

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Griseofulvin is an antifungal medication that has no activity against tinea versicolor. Griseofulvin can only be used to treat dermatophyte infections (eg, tinea pedis, corporis, capitis, cruris). It is inactive against candida organisms and deep fungal infections, as well. Remember that fungal infections involving the hair and nails must be treated with oral antifungal medications, such as griseofulvin or terbinafine.

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Gross dilation of the large bowel is characteristic of toxic megacolon.

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Haemophilus influenzae is another common cause of pneumonia and upper respiratory complaints in children and adults. It is more common when patients with cystic fibrosis are younger than age 5 and it is the second most common organism until around age 10.

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Heart failure can be diagnosed by seeing cardiomegaly or pulmonary edema on CXR or a decreased EF on transthoracic echocardiogram, but is ultimately a clinical diagnosis. No specific test is necessary. The diagnosis of heart failure is made with the Framingham Criteria which have major and minor criteria. 2 major or 1 major and 2 minor criteria are needed for diagnosis. The criteria are listed below. As you can see, two major criteria can be achieved without the use of imaging or echocardiogram. However, once the diagnosis is made with clinical criteria, an echocardiogram should be obtained to determine whether or not there is a reduced ejection fraction. Framingham Criteria: Major criteria: Paroxysmal nocturnal dyspnea or orthopnea Neck vein distention Rales Cardiomegaly S3 gallop Hepatojugular reflux Acute pulmonary edema Minor criteria: Bilateral ankle edema Nocturnal cough Dyspnea on ordinary exertion Hepatomegaly Pleural effusion Tachycardia (heart rate>120 beats/min.) There can be abnormalities seen on stress testing, EKG, or chest CT, but these are not the most helpful studies to make the diagnosis. Transesophageal echo shows the valves of the heart in more detail but is more invasive, and transthoracic echo is more readily available. If imaging was ordered, a CXR and echocardiogram would be the most helpful initial imaging in this patient.

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Hemophilia is caused by a deficiency in clotting factors that lead to a bleeding diathesis. The various subtypes are classified based on which factor is lacking. Hemophilia A is caused be a deficiency of factor VIII and is the most common severe congenital clotting deficiency. Patients with hemophilia present with spontaneous hemorrhage into the tissues and joints. If left untreated, hemarthroses can lead to joint destruction and arthropathy. Patients may also present with spontaneous intracerebral hemorrhages, renal and retroperitoneal bleeding, or gastrointestinal (GI) bleeding.

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Hepatic adenomas are benign liver tumors often seen in young women and most commonly in the right hepatic lobe. They have a strong association with oral contraceptives. Notably, needle biopsy is not recommended to confirm diagnosis as these tumors have a high propensity to bleed. Diagnosis is often made by the combination of clinical history and imaging or, if indicated, by surgical excision. These facts are all highly tested.

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Hepatic encephalopathy presents with asterixis and lethargy and confusion that are due to ammonia accumulation. Management is typically with oral lactulose. Although this may be present now that he is getting confused, ultimately, it is secondary to underlying cirrhosis.

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Hereditary hemochromatosis is characterized by diabetes, skin pigmentation, and cirrhosis of the liver. It is caused by iron accumulation. Most patients are asymptomatic (75%) and are diagnosed when elevated serum iron levels are noted on a routine chemistry screening panel or when screening is performed because a relative is diagnosed with hemochromatosis. Early symptoms include severe fatigue (74%), impotence (45%), and arthralgia (44%); fatigue and arthralgia are the most common symptoms prompting a visit to a physician. The most common signs at the time of presentation are hepatomegaly (13%), skin pigmentation, and arthritis. true or false

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Heroin is a type of opioid, and causes the classic triad of decreased consciousness, pinpoint pupils (miosis), and respiratory depression.

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Hydrops fetalis is associated with severe anemia and isoimmunization.

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Hypertensive emergencies are associated with elevated blood pressures, usually >179/119 mmHg. Other clinical manifestations include retinal hemorrhages and exudates, papilledema, malignant nephrosclerosis (leading to acute renal failure, hematuria, and proteinuria), and neurologic symptoms due to intracerebral or subarachnoid bleeding, lacunar infarcts, or hypertensive encephalopathy. Hypertensive encephalopathy, which is related to cerebral edema, is characterized by the insidious onset of headache, nausea, and vomiting, followed by nonlocalizing neurologic symptoms such as restlessness, confusion, and (if not treated) seizures and coma. These symptoms differ from the abrupt onset of focal neurologic symptoms associated with stroke or hemorrhage; however, stroke and hemorrhage should be ruled out because the patient's blood pressure should not be lowered aggressively if the patient is having a stroke or hemorrhage. The initial aim of treatment is to rapidly lower the diastolic pressure to 100 to 105 mmHg within 2 to 6 hours. The blood pressure should not be dropped by more than 25% of the presenting value. Medications that can be used to achieve this include intravenous nitroprusside, nicardipine, clevidipine, labetalol, and fenoldopam. Patients who have severe hypertension (>179/119 mmHg) without symptoms and signs of end-organ damage are diagnosed with hypertensive urgency. Like hypertensive emergency, hypertensive urgency occurs most commonly in patients who have been nonadherent with their chronic antihypertensive medications. It can also occur in patients who have been noncompliant and who have ingested a large quantity of sodium. However, unlike hypertensive emergency, there is no proven benefit from rapid reduction of blood pressure in patients with hypertensive urgency. In addition, myocardial or cerebral ischemia can be precipitated by overly rapid blood pressure lowering. In many cases, blood pressure may decline spontaneously by allowing the patient to rest in a quiet room. The goal of management of hypertensive urgency is to lower the blood pressure to <160/100 mmHg over several hour to days. For previously treated patients, you can restart or adjust the dosing of the existing medication regimen. For untreated patients, you can start a calcium channel blocker, beta-blocker, or angiotensin converting enzyme (ACE) inhibitor. You should not start a diuretic alone.

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Hypokalemia is caused by thiazide/loop diuretics, inadequate dietary consumption, diabetic ketoacidosis, and hypomagnesemia, among others. One of the manifestations of multiple myeloma is proximal renal tubular acidosis, which is a result of impairment of bicarbonate reabsorption in the proximal renal tubule. Proximal RTA can cause hypokalemia. However, hypokalemia is less frequently seen than hypercalcemia as an electrolyte disturbance in multiple myeloma and does not cause confusion or constipation.

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Hypothyroidism commonly manifests as a slowing in physical and mental activity but may be asymptomatic. Classic signs and symptoms (eg, cold intolerance, puffiness, decreased sweating, and coarse skin) may not be present as commonly as was once believed. Individuals can also present with obstructive sleep apnea (secondary to macroglossia) or carpal tunnel syndrome. Women can also present with galactorrhea and menstrual disturbances. Myxedema coma is a severe form of hypothyroidism that results in an altered mental status, hypothermia, bradycardia, hypercarbia, and hyponatremia. Cardiomegaly, pericardial effusion, cardiogenic shock, and ascites may be present. Myxedema coma most commonly occurs in individuals with undiagnosed or untreated hypothyroidism who are subjected to an external stress, such as low temperature, infection, myocardial infarction, stroke, or medical intervention (eg, surgery or hypnotic drugs).

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In failure to thrive, the most important workup includes a good history and physical exam. If the weight loss is severe or there is specific suspicion for underlying disease, then laboratory workup should be performed, including a CBC, BMP, bilirubin, glucose, venous blood gas, blood ammonia, serum lactate, and urinalysis.

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In hemochromatosis, iron excess is known to be responsible for hypermelanosis. The brownish discoloration of the skin in hemochromatosis may be dependent to some degree on hemosiderin accumulation. This patient is too young for hemochromatosis to present. It usually appears in the fourth or fifth decade of life.

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In myasthenia gravis, single-fiber electromyography testing of the frontalis muscle can be performed to establish diagnosis with good sensitivity and specificity. Additionally, if disease is purely ocular, single-fiber electromyography is superior to the acetylcholine receptor antibody test in diagnosing this condition.

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In patient's with significant PAD, compression stockings are contraindicated as they can further impede arterial circulation and worsen limb ischemia. The other options are all generally accepted treatments for PAD with the exception of atenolol. Recent meta-analysis and randomized trials have shown that patients with PAD are not harmed by the addition of a beta blocker. At least one trial has shown that patients with PAD on beta blockers had a trend toward fewer amputations than their counterparts who were not on beta blockers. We do know that most patients with PAD will also have complications of coronary artery disease or reduced ejection fraction and should be appropriately treated with a beta blocker. PAD is not a contraindication for their appropriate use.

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Liver transplantation should be utilized if all other interventions have failed to resolve ascites. Since approximately 20% of patients with refractory ascites die within 6 months, liver transplantation should be considered as one of the treatment options of patients with refractory ascites. Therefore, liver transplantation evaluation should be considered as a final but critical part of the management of patients with refractory ascites.

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In the setting of iron overload, the storage form of iron, ferritin, should be elevated. Additionally, due to increased levels of iron, a serum iron level should be elevated. This increased serum iron binds to transferrin. Because total body iron is increased, the need for iron transport is decreased, and transferrin levels are decreased. The ratio of increased serum iron to decreased serum transferrin results in an increased transferrin saturation. In patients without secondary causes of anemia, hemochromatosis itself would not change hemoglobin levels. There is plenty of iron available for hemoglobin synthesis.Understanding the physiology of iron transport and absorption can assist you in making the correct choice. Factors that influence ferritin include iron deficiency, which will result in a very low ferritin, and chronic or acute inflammation, which may result in an elevated ferritin because this is felt to be an acute-phase reactant. Additionally, serum transferrin is felt to be an inverse acute-phase reactant and may be decreased by chronic inflammation. Serum iron is generally decreased in the setting of chronic inflammation due to the action of hepcidin.

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Incidence refers to the number of new events in a time interval divided by those individuals at risk. The 50 people with preexisting diabetes are removed from the population because they cannot count as new events. The people who died do not count because they are no longer at risk. The correct answer is to take the 25 new cases and divide that number by the 925 people at risk.

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Infant GERD is a cause of FTT and generally presents with abnormal patterns of regurgitation, pain after eating, food aversion, or weight loss.

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Infectious mononucleosis presents with lymphocytosis, splenomegaly, sore throat, and tender lymphadenopathy. No effective antiviral therapy is available for Epstein-Barr virus (EBV) infectious mononucleosis in immunocompetent persons. Acyclovir and ganciclovir may reduce EBV shedding but are ineffective clinically.

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Inflammation confined to the large bowel is observed in approximately 25% of patients, and is a much less common presentation of Crohn disease.

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Influenza typically has upper and lower respiratory tract symptoms, myalgias, fevers, and weakness. Management is with zanamivir and oseltamivir within 48 hours of exposure, in addition to symptomatic treatment.

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Insertion of a Foley catheter may be performed if a diagnosis of urinary tract obstruction is suspected or if there is an acute outlet obstruction. This patient is still urinating and so the insertion of a catheter is not needed at this time. The post void residual in this patient does not suggest acute retention. In general, it is prudent to make a diagnosis prior to initiating treatment on the boards.

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Intravenous medications that can be used to treat hypertensive emergencies include intravenous nitroprusside, nicardipine, clevidipine, labetalol, and fenoldopam. The blood pressure should never be dropped initially by more than 25% of the initial presenting value, as this may trigger an ischemic event.

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Intussusception is the telescoping of one intestinal segment into another with peristalsis. This occurs secondary to a "lead point" or mass that catches and provides a source of traction. It is characterized by intermittent abdominal pain and a "current red jelly" stool. This patient who lacks abdominal pain is unlikely to have intussusception, although he would be at risk in the future if his Meckel diverticulum is left untreated.

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Intussusception should be suspected in children ages 3 to 18 months of age who present with abdominal pain, leg withdrawal, and "currant jelly" stools that result from mucosal venous congestion. Emergent water-soluble contrast or air enema should be performed for both diagnostic and possible therapeutic reduction of the intussusception. It is successful in at least 80% of children with this condition. Radiologic reduction is contraindicated in patients with free air or peritonitis because prompt operation is necessary. Decompensation in intussusception occurs because part of the bowel telescopes into another part, dragging the mesentery with it. This results in mesentery venous compression, which prevents venous outflow and leads to bowel edema and infarction.Viscerosomatic reflexes are a type of somatic dysfunction caused by changes in the autonomic nervous system. They can be acute or chronic, and are considered to be a somatic representation of visceral disease. When either branch of the autonomic nervous system (sympathetic or parasympathetic) overstimulates a particular organ, a reflex reaction occurs. The soma at the same level of the organ's autonomic innervation takes on characteristics of somatic dysfunction (TART). T8-T12 is where the sympathetic viscerosomatic reflex for the small bowel is located.The osteopathic findings described also illustrate acute findings in somatic dysfunction, versus chronic changes. Acute and chronic somatic dysfunction findings differ in tissue texture changes, restriction, and tenderness. In patients with chronic somatic dysfunction, the tissue texture changes are cool, dry, flaccid, ropy, and fibrotic. The restriction is present, but there is decreased or no pain. Tenderness in chronic somatic dysfunction is described as dull, achy, and burning. Acute tissue texture changes are edematous and erythematous, with increased tonicity of muscles. The restriction is present, and is painful with movement. Acute tenderness is described as severe and sharp.

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Iodine is a trace mineral associated with homeostasis of the thyroid gland. Iodine is present within some soil, water, fish, seafood, and various vegetables. Its absence in soils of various parts of the world had led to deficiencies historically. Fortification with table salt has resulted in a dramatic reduction of this.Physiologically, the role of iodine is limited to the setting of thyroid function. Deficiency is associated with hypothyroidism, subsequent goiter, mental slowing, coma, and metabolic syndrome if left unchecked. Although a long-standing iodine deficiency may result in glucose intolerance, it does not have a relationship with catabolic states such as burns, and the associated metabolic syndrome usually is a later complication not seen in this acute setting.

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Iron deficiency anemia presents with low iron, low ferritin, elevated total iron-binding capacity, and low transferrin saturation. Iron deficiency anemia presents commonly in women of reproductive age because of menstrual blood loss. An older patient presenting with iron deficiency anemia points to blood loss from other sources, and a slow gastrointestinal bleed must be excluded. Colon cancer could be a cause of chronic, asymptomatic blood loss.The first test of choice is fecal occult blood testing (FOBT) because it is noninvasive and inexpensive. However, its specificity and sensitivity are low; thus, results must be interpreted with caution. In this patient with a recent colonoscopy, a negative FOBT would be reassuring and should lead to a search for other causes of iron deficiency, such as malabsorption. If the FOBT was still positive, then consideration could be made for esophagogastroduodenoscopy (EGD) with or without repeat colonoscopy. Further signs of blood loss with negative EGD and colonoscopy would likely require a capsule endoscopy evaluation.

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Lysergic acid diethylamide, also known as LSD, causes "enhanced sensation": colors are richer, music is more profound, and tastes are heightened. This is a psychoactive medication that does not usually lead to increased sympathetic tone or myocardial infarction.

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It could be argued in this question given this patient's issues with follow-up and significant weight loss that a trial of pharmacologic therapy should be tried immediately. This is reasonable and was considered neutral as pharmacologic therapy should still be paired with lifestyle interventions. This will require shared decision-making with the patient's family. While reflux in infants is generally well tolerated, progression to GERD generally requires some form of intervention. The most appropriate initial treatment for infants and children is simple life-style modifications to minimize regurgitation. These include smaller, more frequent meals, adding thickening agents (can cause weight gain, but this child is underweight), and anti-regurgitant formulas (decrease observed regurgitation but not number of episodes, it just tends to stay in the lower esophagus more, which may be swallowed again). Hydrolyzed formulas can be used if it is felt there is a component of allergies to milk proteins, and for breastfeeding infants, removing eggs/cows milk and other immunogenic foods from the mother's diet may help. Also, adjusting the infant position after feeding to remain upright for at least thirty minutes can reduce reflux. The prone and left-side down positions have been shown to be associated with fewer episodes of reflux, but should only be tried if the infant is awake as these positions are associated with sudden infant death syndrome. There are infant sleepers which are meant to hold infants in certain positions and have been approved by the FDA for GERD treatment; however, they have also been associated with several deaths and should only be used with extreme caution. If an infant fails conservative management and continues to have troublesome symptoms, an empiric trial of acid suppression can be tried using either a H2 antagonist or a proton pump inhibitor (PPI). If reflux does not respond to pharmacological treatment and lifestyle modification, then upper endoscopy should be considered for evaluation of other complicating conditions, including eosinophilic esophagitis, esophageal webs, strictures, achalasia, or infectious esophagitis.

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It is not safe for pregnant women to eat cold cuts because of bacteria such as Listeria monocytogenes which can cause food poisoning with listeriosis. Listeriosis can cause meningitis and sepsis. Meningitis can lead to paralysis, mental illness, disability, and death because it affects the brain. Listeria can also reach the baby through the placenta, causing preterm labor, miscarriage, or other damage to the baby so it is very important to avoid deli meats in pregnancy.

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Kawasaki disease, also known as mucocutaneous lymph node syndrome, is a medium vessel vasculitis that presents with conjunctivitis, rash, adenopathy, strawberry tongue, and skin desquamation along with high fever for greater than five days' duration. Management is with a high dose of aspirin and IVIG to prevent coronary artery aneurysms.

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Klebsiella pneumoniae is a common cause of pneumonia in alcoholics and can be associated with aspiration. It sometimes cavitates in the lungs. It may present with currant jelly red sputum. It is not a common organism associated with cystic fibrosis.

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Knowing the general treatment for the severe forms of valvular disease is probably adequate for the level 3 exam. Below is a list of indications for valvular surgery, however, knowing all of them will be low yield. Simply being able to recognize that a patient has a severe valvular problem and will require surgical intervention will usually be enough. Additionally, asking about murmur types and sounds has been a long-time favorite exam question and at least remembering a few of the classic murmurs can be beneficial. Indications for aortic valve surgery are as follows:-symptomatic patients with severe AR regardless of LV systolic function.-asymptomatic patients with chronic severe AR and evidence of LV systolic dysfunction with an EF 50 mm-asymptomatic patients with severe AR and normal LVEF, but with progressive severe LV dilation (LVEDD >65 mm), if surgical risk is low.-patients with severe AR while undergoing cardiac surgery for other indications.-patients with moderate AR who are undergoing other cardiac surgery.The patient listed above is symptomatic with severe AR based on his austin flint murmur, and so would be a candidate for surgery.

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Kwashiorkor is protein-energy malnutrition manifested often in children with thin bodies but very protuberant abdomens secondary to protein shifts.Kwashiorkor is characterized by symmetric peripheral pitting edema that begins in the most dependent regions and proceeds cranially as time progresses, with or without anasarca.Other physical examination findings include:Apathetic, listless affectRounded prominence of the cheeks ("moon face")Pursed appearance of the mouthThin, dry, peeling skin with confluent areas of hyperkeratosis and hyperpigmentationDry, dull, hypopigmented hair that falls out or is easily pluckedHepatomegaly (from fatty liver infiltrates)Distended abdomen with dilated intestinal loopsBradycardia, hypotension, and hypothermia

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Late decelerations are caused by decreased blood flow to the placenta and can signify fetal acidemia. The management of late decelerations is to enhance uteroplacental blood flow by correcting the underlying cause, increasing fetal PO2, and correcting fetal acidemia. This can be accomplished by the following: 1. Repositioning the mother to left lateral position, right lateral or knee-chest position, in an attempt to relieve vena cava compression by the uterus and increase venous return and cardiac output.2. Increase intravascular volume by adding IV fluids.3. This is conflicting data, but most guidelines still recommend administering supplemental oxygen.4. Discontinuing uterotonics to assist with uterine relaxation. Decreased contractions can help improve blood flow to the placenta. 5. Emergent operative vaginal delivery or cesarean delivery as the last resort if the fetal heart rate variability pattern does not improve.

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Legg-Calvé-Perthes disease is avascular necrosis of the hip that most commonly occurs in male children between the ages of 4 and 12 years. Patients present with a limp that may or may not elicit pain. Management is splinting and decreased weight bearing.

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Levetiracetam (Keppra) is a non-benzodiazepine anti-seizure medication. It should be started once the patient has already received Lorazepam. Levetiracetam needs time to become therapeutic which is why it is not first line. It also takes too long to obtain levetiracetam levels in the urgent setting of status epilepticus. Lorazepam has a much shorter time of onset. The primary role of the non-benzodiazepine antiseizure drug is to prevent recurrence rather than break the seizures.

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Lidocaine is commonly used in the emergency department for numbing the skin prior to suturing because of its rapid onset and potent localizing effects. In this scenario, the best preparation would be to add epinephrine 1:100,000 to the local anesthetic mixture prior to suturing. Epinephrine is used in dilute concentrations for its vasoconstrictive properties to counteract vasodilatation caused by the injection of the local anesthetic. Epinephrine also lengthens the duration of the block and increases the amount of local anesthetic that can be injected without the possibility of incurring local anesthetic toxicity. It accomplishes both of these by slowing the uptake of the local anesthetic into the bloodstream.Because of its vasoconstrictive properties, it was once thought that epinephrine should not used in skin with limited vascular supply, such as in the terminal extremities (fingers and toes) and the nose. This was primarily a theoretical concern, and studies over the past several years have disproved this long-held medical school teaching.

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Meckel's diverticulum is a remnant of the omphalomesenteric duct. It is usually asymptomatic but in symptomatic patients it may cause GI bleeding with right lower quadrant pain. It follows the rules of 2's (i.e. 2% of patients are symptomatic, it occurs in 2% of the population, and it is 2 feet proximal to the ileocecal valve). Diagnosis is made with a technetium-99m pertechnetate scan. Treatment is surgery. Complications include volvulus and intussusception.

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Meckel's diverticulum is the most common malformation of the intestinal tract, occurring in up to 2% of the population. The single most common presenting symptom is painless rectal bleeding in the form of melena, followed by intestinal obstruction from volvulus or intussusception. Occasionally the patient may suffer from painful diverticulitis mimicking appendicitis. Meckel's diverticulum is located in the distal ileum, usually within about 60-100 cm of the ileocecal valve. Remember the rule of 2's when making the diagnosis: 2% (of the population), 2 feet (from the ileocecal valve), 2 inches (in length), 2% are symptomatic, 2 types of common ectopic tissue (gastric and pancreatic), age 2 the most common age of presentation, and males are 2 times as likely to be affected than females.

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Melanoma is an increasingly common malignancy that can be cured with early detection and excision. Breslow depth is the measured vertical thickness of the melanoma and is the single most important prognostic factor. Clark level involves an anatomic level of invasion. Management of a melanoma is dependent on the depth of invasion and the stage of the melanoma. Melanomas of >0.8 mm thickness or <0.8 mm with ulceration are the accepted indications for sentinel lymph node biopsy. Management of a positive sentinel lymph node has become controversial. Historically, a positive sentinel lymph node resulted in a complete lymphadenectomy. However, recent data suggest observation with serial ultrasonography may be adequate. Melanoma in situ (not penetrating the epidermis) requires excision with 5-mm margins. Depending on the stage of the disease, the excision margins, and sentinel lymph node biopsy, use of adjuvant treatment, such as oncologic drugs, may be warranted. There are currently new drugs, such as BRAF inhibitors, that are being used in the treatment of metastatic disease with good results.

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Meningitis B is recommended for teens and young adults ages 16-23. It is not routinely recommended for older adults unless there is an increased risk for meningococcal disease.

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MetHb can be caused by any substance that acts as an oxidant stressor, such as nitrite or sulfur containing compounds, sepsis, and local anesthetics. Mountain water contains high levels of nitrites, which is most likely the cause in this case. MetHb can be treated with intravenous (IV) methylene blue, which reduces the oxidized heme groups.

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Metoprolol is a selective beta-blocker. This class of drugs is contraindicated in patients who use cocaine because of the mechanism of action. By blocking beta-receptors, cocaine may allow unopposed alpha activation and exacerbate high blood pressure, causing hypertensive emergency and worsening end organ damage.

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Mitral regurgitation is an incompetence of the mitral valve. Common causes include mitral valve prolapse and ischemic heart disease, causing papillary muscle rupture. Cardiac auscultation reveals a harsh blowing, holosystolic murmur radiating from the cardiac apex to the axilla with a mid-systolic click. Symptoms present with right ventricular failure due to a fluid overload of the right heart. Treatment is typically based on symptoms, with valve repair or replacement required if a hemodynamic compromise occurs.

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Mitral valve prolapse is a relatively benign finding that presents on physical exam with a mid-to-late systolic click, which may be followed by a high-pitched crescendo-decrescendo late systolic murmur over the cardiac apex.

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Most babies have a component of reflux after meals and it is very common for babies to continue to have gastroesophageal reflux into their first year of life, however, the reflux should not interfere with normal growth and development. This child also has other clues to the diagnosis of GERD, including her tendency to be upset after eating, roll around, and arch her back, which are all likely due to abdominal pain. She also may skip meals because of pain after eating which represents a conditioned response. Other diagnosis can be ruled out by history. She does not have signs of malabsorption as she does not have significant diarrhea or flatulence and her celiac screen was negative. She also has normal cellular counts and electrolytes, indicating adequate nutrient intake for electrolyte maintenance and cellular development. She does not have growth restriction, because her head circumference and length have continued to grow as expected. Only her weight has been affected. She does not have social issues and food scarcity is not a problem, as she actually eats slightly more than the recommended amount for her age and seems to have a good relationship with her mother. Eating more than recommended is common in babies with GERD and can either be the cause of the problem (too much food causes worsening GERD due to stomach distention) or can be compensation due to lost food with chronic regurgitation. She does not have allergies to her formula as this commonly presents on the initiation of feeding within the first month of life or within 1 week of changing formula. She has been using the same formula since shortly after birth. She does not have projectile vomiting to indicate pyloric stenosis. Reflux generally peaks around 4 months of age, with 2/3 of infants having an episode of reflux at least once daily and approximately 40% will regurgitate with most feedings. After 4 months, regurgitation generally drops off. This patient is 6 months old, so it is very atypical to continue to have regurgitation with every meal.

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Multiple electrolytes and dextrose injection is also a crystalloid solution that has a physiologic profile even closer to that of lactated Ringer's; however, it is not used at most centers due to its high cost. Studies have not shown PlasmaLyte to be beneficial over lactated Ringer's, and it is not the most cost-effective approach to successful fluid resuscitation.

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Narcolepsy is characterized by a tetrad of symptoms including excessive daytime sleepiness, cataplexy, hypnagogic hallucinations, and sleep paralysis; however, patients usually have excessive daytime sleepiness as the only presenting symptom.

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Necrotizing enterocolitis typically presents with a history of premature delivery. Imaging will reveal a pneumoperitoneum and portal venous gas. It occurs in infants of up to three months of age and patients typically have rectal bleeding, abdominal distension, and emesis. Treatment is bowel rest, antibiotics and surgery if refractory.

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The patient is having a seizure in pregnancy, which is called eclampsia. Patients who develop this condition usually have symptoms of preeclampsia prior to the seizure. Preeclampsia is a condition that develops in pregnancy with elevated blood pressure and proteinuria that resolves after delivery. Symptoms of preeclampsia are changes in vision, headaches, swelling, scotomas, and right upper quadrant pain. When a seizure occurs, prompt treatment with magnesium sulfate should occur. Once the patient is stabilized, regardless of gestational age, delivery is indicated.

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Neurofibromatosis type 1 is also known as von Recklinghausen disease and is an autosomal dominant condition. The condition can also be due to a spontaneous mutation. The disease is due to a genetic defect on a tumor suppressor gene of chromosome 17, which codes for neurofibromin. The condition affects the skin, nervous system, eyes, bone, and soft tissue. The diagnostic criteria include 2 or more of the following:1. 6 or more café-au-lait macules greater than 5 mm in prepubertal individuals or greater than 15 mm postpubertal individuals2. 2 or more lisch nodules (iris hamartomas)3. Sphenoid dysplasia4. 2 or more neurofibromas5. Freckling in axillary or inguinal region (also known as Crowe sign)6. Optic glioma7. First-degree relative with the condition

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Neurofibromatosis type 2 is an autosomal dominant condition. Patients present with bilateral acoustic neuromas, which are schwannomas of the eighth cranial nerve. It is associated with chromosome 22 and codes for merlin. These patients have fewer café-au-lait macules and do not form lisch nodules.

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Neurosyphilis is an unlikely cause of this patient's presentation given the absence of hyporeflexia and sensory involvement along with a negative Romberg sign. Signs of neurosyphilis include hyporeflexia, sensory impairment, pupillary changes, cranial neuropathy, dementia, mania, or paranoia, positive romberg sign, charcot joint, hypotonia, and optic atrophy.

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Obstructive sleep apnea (OSA) is characterized by recurrent episodes of upper airway obstruction that occur during periods of sleep that cause intermittent hypoxia and recurrent arousals. Patients usually present with snoring that is bothersome to others, restless sleep, daytime somnolence/fatigue, headaches, and witnessed periods of apnea. Usually, patients with OSA are obese and have a neck circumference greater than 40 cm. Chronic OSA patients will have tachycardia, hypertension, and low oxygen saturation.

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Obstructive uropathy should be considered in patients with any of the following: diminished or absent urine output unexplained renal insufficiency pain that suggests distention in the urinary tract a pattern of oliguria or anuria alternating with polyuria BPH is a cause of post-obstructive nephropathy. The pathophysiology involves the development of multiple fibroadenomatous nodules in the periurethral region of the prostate, probably originating within the periurethral glands rather than in the true fibromuscular prostate (surgical capsule), which is displaced peripherally by progressive growth of the nodules. As the lumen of the prostatic urethra narrows and lengthens, urine outflow is progressively obstructed. Increased pressure associated with micturition and bladder distention can progress to hypertrophy of the bladder detrusor, trabeculation, cellule formation, and diverticula. Incomplete bladder emptying causes stasis and predisposes to calculus formation and infection. Prolonged obstruction, even if incomplete, can cause hydronephrosis and compromise renal function. The time span of his symptoms is not mentioned in the stem; however, the likely cause of his renal insufficiency still would likely be BPH in this patient even with the presence of mild hydronephrosis on renal ultrasound.

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Oral estrogen is contraindicated in a patient who smokes as this will increase the likelihood of developing blood clots. It is also contraindicated in a woman with a uterus when used as monotherapy. In a patient with a uterus, combined progesterone and estrogen would be the treatment of choice for postmenopausal symptoms including hot flashes.

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Orthostatic hypotension is defined as a blood pressure drop of more than 20/10 mmHg within 3 minutes of standing from a seating or lying position, and it has many causes. It is caused by the inability of the sympathetic nervous system to vasoconstrict in response to a decrease in pressure at the baroreceptors. Terazosin is an alpha-blocker thus blocking the sympathetic response.

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Orthostatic hypotension is uncommon in the healthy elderly. However, it occurs in 30-50% of elderly persons with known risk factors and is another example of a multifactorial geriatric syndrome similar to falls and delirium. Most patients with orthostatic hypotension have either no symptoms or atypical symptoms, and therefore, screening blood pressure should be taken in all patients with risk factors. Orthostatic hypotension is a known side effect of alpha-2 adrenergic agonists. Clonidine is a common drug in this class and is used for the treatment of hypertension, especially in patients who also suffer from BPH. Treatment is cessation of the possible causative medications and idealization of medical therapy. Elevated head position at night can be beneficial. Midodrine is the only FDA approved medication for orthostatic hypotension.

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Osgood-Schlatter affects the tibial tuberosity and shows calcification on plain radiograph.

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Osgood-Schlatter disease is osteochondritis of the tibial tubercle secondary to overuse. It occurs in taller children who are active and between 10 and 15 years old. Patients complain of knee pain and may present with a limp. Physical examination reveals knee swelling, bony prominence of the tibial tubercle, and tenderness during palpation. Treatment is conservative.

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Osgood-Schlatter disease predominantly affects male teenagers who are active and have recently had growth spurts in addition to radiographic findings that are typically irregular ossification of the proximal tibial tuberosity and calcification within the patellar tendon. It is typically a benign and self-limited condition, and the mainstays of treatment are pain control and maintenance of range of motion at the knee as avoidance of activity is not recommended.

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Osteomalacia is a condition caused by defective bone mineralization primarily due to vitamin D deficiency. Causes include inadequate sun exposure, poor dietary intake (common in vegans), chronic kidney disease, and problems with malabsorption (such as post gastric bypass or in celiac disease). Osteomalacia can also be caused by hypophosphatemia (such as in Fanconi syndrome) or from certain medications (such as bisphosphonates). During bone turnover, the decreased mineralization causes focal accumulation of newly formed osteoid. Radiographically this manifests as radiolucent lines with sclerotic borders commonly known as "pseudofractures"; the combination of multiple symmetric and bilateral pseudofractures is known as Milkman syndrome.

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Untreated UTIs in pregnant patients can lead to an increased risk for the following sequelae: Preterm labor, second-trimester abortions, preeclampsia, maternal anemia, and amnionitis.COMBANK Insight : COMLEX Level 3 Insight: COMLEX questions focus on prevention of mortality and morbidity, especially in pregnant patients.

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Osteopathic pearl: The patient's physical examination is significant for palpable lymph nodes; osteopathic techniques can be used to address the patient's lymphatic system. Lymphatic treatments can be divided into two categories: those that improve restrictions and those that augment lymphatic flow. Treatment protocols should include techniques from both categories. First, start with techniques that remove restriction, and then apply techniques that augment flow. The treatment sequence is as follows: Treat any thoracic inlet somatic dysfunction. Do rib raising or paraspinal inhibition. Redome the thoracoabdominal diaphragm. Apply lymphatic pump techniques. Before performing these techniques, keep in mind the following relative contraindications: Osseous fractures Bacterial infections with a temperature > 102°F Abscess or localized infection Certain stages of carcinoma

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Osteoporosis is a common metabolic bone disease characterized by decreased bone strength and abnormal bone density. It is more common in inactive, postmenopausal, Caucasian women. Patients with osteoporosis may present with hip fracture or vertebral compression fractures. The patient has multiple risk factors for osteoporosis, including a thin build, a longstanding history of tobacco use and a low mechanism fall. All patients greater than 65 years of age, as well as patients between 40 and 60 years of age with at least one risk factor for fractures after menopause, should be screened with a DEXA scan of the spine and hip. Secondary causes of osteoporosis include smoking, alcoholism, renal failure, hyperthyroidism, multiple myeloma, hyperparathyroidism, vitamin D deficiency, hypercortisolism, and heparin and chronic steroid use. The most appropriate first step in the work up of this patient should be to order a DEXA scan. A T-score of below -2.5 indicates osteoporosis. Treatment is indicated with a T-score is < -2 or < -1.5 in a patient with risk factors. Management involves the use of bisphosphonates, teriparatide, selective estrogen receptor modulators, and intranasal calcitonin.

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Osteosarcoma has been known to metastasize to pulmonary structures. CT scanning of the chest is more sensitive than plain film radiography for assessing pulmonary metastases. Ideally, obtain the CT scan of the chest before performing a biopsy to avoid ambiguity that can arise from postanesthesia atelectasis. CT scanning of the primary lesion also helps delineate the location and extent of the tumor and is critical for surgical planning. In additional to a CT chest to evaluate for pulmonary metastases, radionuclide bone scanning with technetium-99 is important to evaluate for the presence of other metastatic lesions.

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Parathyroid tissue consists of 4 glands (2 pairs), with each pair located close to upper and lower poles of the posterior thyroid lobe. Parathyroid tissue releases parathyroid hormone, which is controlled by ionized calcium by a negative feedback mechanism. Parathyroid glands are identified and preserved during thyroid surgery, with close monitoring of serum calcium. Calcium is primarily absorbed in the duodenum, which has the highest concentration of calcium transporters. Since ingested food bypasses the duodenum after a gastric bypass (GBP) surgery, total body calcium levels may further decrease, placing the patient at higher risk of osteoporosis. Acute hypocalcemia may present as perioral numbness/tingling, muscle cramps, or seizures if severe. In patients with a possible underlying calcium deficiency, it is important to take extra care in preserving parathyroid tissue during thyroid surgery.

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Patients going through cocaine withdrawal will have symptoms very similar to major depressive disorder including increased sleep, appetite, psychomotor slowing, severe depression and suicidal ideation. They may also have pains, tremors, chills and involuntary motor movements. Give supportive treatment. true or false

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Patients suffering from basilar skull fractures typically present with ecchymosis to the mastoid processes (Battle's sign) and bilateral periorbital ecchymosis (raccoon eyes) and may have bleeding from the ears and CSF rhinorrhea.

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Patients taking aminoglycosides for more than two weeks are at risk for developing ototoxicity, especially with co-administration of loop diuretics.

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Patients who present with a "gush of fluid" should be suspected of having ruptured membranes, although this is often mistaken for stress incontinence related to pregnancy. Patients suspected of having ruptured membranes should undergo speculum examination for vaginal pooling, along with nitrazine and fern tests for confirmation. These tests are described below.Vaginal pooling: A sterile speculum is used to examine the vaginal vault. Pooling appears as a collection of fluid in the vagina, which can be enhanced by having the patient Valsalva to promote fluid escaping from the cervix.Nitrazine test: Vaginal secretions tend to be acidic compared to amniotic fluid, which is alkaline. If amniotic fluid is present, the nitrazine paper will turn blue due to the alkaline environment, indicating a positive test.Fern test: Estrogens in the amniotic fluid cause crystallization of amniotic salts, which appear as blades of a fern on microscopic evaluation, indicating a positive test.

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Patients who present with a hyperosmolar hyperglycemic state (HHS) are profoundly dehydrated. Once the diagnosis is made, they should receive an initial bolus of isotonic fluids (1-2 liters). Isotonic fluids should be continued until hypotension and mental status improve. After correction of hypotension and improvement of mental status, the corrected serum sodium should be calculated. For a corrected sodium > 135, fluids should be switched to half-normal saline. If corrected sodium remains < 135, continue with normal saline. Dextrose should be added to the solution when glucose levels reach 300 mg/dL or less.

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Patients with a history of cardiotoxicity should avoid therapy with citalopram.

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Patients with hemochromatosis may present with abdominal pain, symptoms of diabetes such as polyuria and polydipsia, hypogonadism, arthropathy (generally of the hands), bronzing of the skin, hepatomegaly (with or without cirrhosis), or cardiac dysfunction (with or without clinical heart failure).

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The patient is suffering from an anatomic short leg following right hip replacement surgery. This diagnosis is made based on structural examination with leg length discrepancy and measurements of sacral base tilt and femoral heads on radiographic imaging. As long as the prosthesis and bony anatomy are intact, appropriate initial treatment is a heel lift orthosis on the side of the shorter leg. It important to note that the patient is standing so both feet are even on the floor during postural radiograph. Therefore, the longer leg will show a higher femoral head. The left leg is the shorter leg based on radiographic imaging, which means the patient would need a heel lift on her left side.

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Patients with history of heavy cocaine abuse that cease use often go through withdrawal that has prominent psychiatric features but is rarely medically serious. They may have depression, anxiety, fatigue, decreased concentration and anhedonia. Often they have increased appetite and sleep most of the day. Some complain of increased dreaming secondary to greater amounts of REM sleep. The typical "crash period" is characterized by psychomotor retardation, severe depression and often suicidal ideation. Physical signs include musculoskeletal tenderness, tremors, chills, involuntary motor movement, and possibly myocardial ischemia in the first week due to coronary vasospasm. Treatment for these patients is supportive. Watch for major depression and suicidal ideation. Patients going through cocaine withdrawal will have symptoms very similar to major depressive disorder.

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Patients with marasmus are typically very thin, because they are not only deficient in protein calories but also in all caloric intake.Other physical examination findings may include:Head that appears large relative to the body, with staring eyesEmaciated and weak appearanceBradycardia, hypotension, and hypothermiaShrunken arms, thighs, and buttocks with redundant skin folds caused by loss of subcutaneous fatThin, sparse hair that is easily plucked

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Patients with measles typically present with high fever, cough and runny nose three days prior to the onset of rash.

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Patients with multivessel CAD and a low ejection fraction should undergo CABG. Primary prevention ICD implantation in heart failure patients should wait > 40 days after MI or > 90 days after revascularization (with optimal medical therapy) to ensure the ejection fraction is still less than 35%.

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Per the American College of Obstetricians and Gynecologists, women should start cervical cancer screening at 21 years old, regardless of sexual history. They should continue screening every 3 years until age 29. After that, they can be screened every 3 years with a Pap smear or be screened every 5 years with a Pap smear and HPV testing.

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Peripheral flow cytometry should be obtained in this patient to evaluate an elevated white count with lymphocytic predominance as the likely cause of his hemolytic anemia. This answer was considered neutral.

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Persons with decision-making capacity have the right to refuse both surgical and medical care at any time. Any physician can determine whether a patient has decision-making capacity. COMBANK Insight : Always remember that it is your job to protect a patient's autonomy and respect their wishes in the medical decision-making process.

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Phencyclidine piperidine, also known as PCP, causes vertical and horizontal nystagmus, intense psychosis, violence, rhabdomyolysis, and hyperthermia. Patients may also have hypertension (60%) and tachycardia (30%) but they would not have coronary vasospasm resulting in myocardial infarction.

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Phenobarbital is another non-benzodiazepine anti-seizure medication, but it is less favored than phenytoin, levetiracetam, or valproic acid. It also should not be the initial medication given for a seizure as it does not work acutely. It is reserved as 3rd line in the treatment of status epilepticus.

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Phenytoin (Dilantin) is another non-benzodiazepine anti-seizure medication. It should be started on the patient once he has already been given Lorazepam to acutely control the seizure. Phenytoin will take time to become therapeutic. The primary role of the non-benzodiazepine antiseizure drug is to prevent recurrence rather than break the seizures.

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Physical exam in patients with aortic regurgitation presents with a blowing diastolic murmur at the left sternal border.

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Physical therapy and heel supports are first-line therapy in the treatment of plantar fasciitis.

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Physicians are not legally obligated to accept new patients to their practice.

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Physostigmine is a short-acting cholinesterase inhibitor and can be used to treat some anticholinergic toxicities. However, it is contraindicated in tricyclic antidepressant overdose due to an increased risk of bradycardia, seizure, and asystole.

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Placental separation describes placenta abruption, which is often associated with fetal distress.

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Plain films of the abdomen should be performed due to suspected small bowel obstruction and will show "air-fluid levels" and dilated loops of small bowel. Recall that intra-abdominal adhesions are the cause of mechanical small bowel obstruction in 75% of cases. The development of abdominal adhesions is often due to foreign body reaction to exposed sutures, serosal irritation, spilled intestinal contents, and talc from personal protective equipment. For those adhesions not caused by previous surgery, malignancy (10%), abdominal wall hernias (5%-7%), internal hernias, volvulus, abscess, intussusception, radiation stricture, gallstone ileus, Meckel diverticulum, and mesenteric ischemia are potential etiologies. Prompt diagnosis and treatment of small bowel obstruction are important to prevent bowel necrosis. Initial management includes nasogastric suction, fluid resuscitation, and supine/upright abdominal radiographs. With medical management, 65%-85% of small bowel obstructions will resolve without further intervention.

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Plasminogen deficiency is a cause of a hypercoagulable state. It would cause signs and symptoms of clotting, not bleeding.

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Polyhydramnios is associated with maternal DM, multiple gestation, isoimmunization, pulmonary abnormalities, duodenal atresia, TE fistula, anencephaly, and twin-to-twin transfusion syndrome.

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Porphyria cutanea tarda (PCT) results from the deficiency of hepatic uroporphyrinogen decarboxylase, which is involved in the metabolism of heme. This disorder is most common in patients with a history of alcoholism, hepatitis C, smoking, or estrogen use. Patients typically present with chronic blistering on sun-exposed areas that fails to heal properly, resulting in erosions and skin hyperpigmentation. On laboratory analysis, there will be decreased levels of uroporphyrinogen decarboxylase and elevated levels of porphyrins in the serum, urine, and feces. Wood's lamp examination of the urine will yield a purple color. Management of PCT involves avoidance of sunlight, alcohol, and excess iron as these will exacerbate the condition. Hemochromatosis is a common result of PCT and is often managed with phlebotomy to remove the excess iron. Other treatment options include the use of low-dose antimalarials such as hydroxychloroquine and chloroquine.

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Preeclampsia with severe features requires any one or more of the following factors:1. Symptoms of central nervous system dysfunction:New-onset cerebral or visual disturbance, such as: Photopsia, scotomata, cortical blindness, retinal vasospasm Severe headache (ie, incapacitating, "the worst headache I've ever had") or headache that persists and progresses despite analgesics Altered mental status 2. Hepatic abnormality:Severe, persistent, right upper quadrant or epigastric pain unresponsive to medication and not accounted for by an alternative diagnosis orserum transaminase concentration ≥ twice normal, or both3. Severe blood pressure elevation:Systolic blood pressure ≥160 mmHg or diastolic blood pressure ≥110 mmHg on 2 occasions at least 4 hours apart while the patient is on bedrest (unless the patient is on antihypertensive therapy)4. Thrombocytopenia:<100,000 platelets/μL5. Renal abnormality:Progressive renal insufficiency (serum creatinine >1.1 mg/dL or doubling of serum creatinine concentration in the absence of other renaldisease)6. Pulmonary edema Patients may also have HELLP syndrome, which stands for hemolysis, elevated liver function tests, and low platelets. Definitive treatment is delivery if the patient is at term. If preterm, delivery of the neonate is advised once the mother is stabilized to prevent the death of both mother and neonate.

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Pregnancy-induced thrombocytopenia can be severe at times. When platelets are decreased, patients can have difficulty with anesthetic options. Regional anesthesia may be withheld due to the risk of bleeding into the epidural space with decreased platelet level. Most anesthesiologists will restrict epidural placement at platelet levels less than 100,000/μL. Women with severe thrombocytopenia can be treated with steroids to accelerate platelet formation. This is usually done about 1 to 2 weeks prior to anticipated delivery to boost platelet levels to optimize the patient's best chance for regional anesthesia. However, this is usually performed with high-dose glucocorticoids rather than betamethasone.

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Pregnant patients with no risk factors should be screened for GDM in the second trimester. Women with increased risk factors, like obesity or previous GDM, should be screened twice--in the first trimester, to decrease the adverse effects of hyperglycemia, and then during the second trimester, to check for GDM. The screening test is performed between 24 and 28 weeks of pregnancy. The test may be done earlier if patients have higher glucose levels checked at routine prenatal visits.

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Propranolol is the treatment of choice for essential tremor. Alongside with primidone, propranolol helps to decrease tremor amplitude in approximately 50-70% of patients. In patient's that along require short-term symptom reduction, alcohol can be used to subside the symptoms, alcohol consumption is not an appropriate maintenance therapy.

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Pulmonary embolus (PE) is a common medical disease with a potentially fatal course. The presentations of PE can range from pleuritic pain and cough to florid respiratory failure and circulatory collapse. The most common presenting symptom of PE is dyspnea, followed by chest pain (classically pleuritic) and cough. Many patients present with vague symptoms which can make the diagnosis challenging. The risk factors for PE are the same risk factors for the development of DVT and include old age, malignancy, immobility, fracture, hospitalization, obesity, pregnancy, previous thromboembolic disease, hormone therapy (including EPO), smoking, and nephrotic syndrome. The diagnosis of PE is with CT angiography and has a very high sensitivity and specificity. If CT angiography is not feasible due to renal failure, a VQ scan can be performed and will give a low, medium, or high likelihood of pulmonary embolus based on VQ mismatching. Invasive catheter angiography is rarely performed anymore except in cases of chronic thromboembolic disease and pulmonary hypertension requiring embolectomy. Patients with PE, like those with DVT, require therapeutic anticoagulation. If clinical suspicion is relatively high, patients can be anticoagulated even before the scan is complete with a single dose of enoxaparin or a heparin drip.This patient likely has a PE. She has multiple risk factors including her age, immobility, previous hospitalization and fracture history. Virchow's triad states that venous thromboembolism (VTE) occurs as a result of alterations in blood flow (ie, stasis), vascular endothelial injury, and alterations in the constituents of the blood (ie, inherited or acquired hypercoagulable state). This patient's VTE was likely mostly due to immobility.

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Pyloric stenosis patients will typically have a bird's beak appearance on x-ray. Patients present with non-bilious projectile vomiting that usually occurs around 4 weeks of age. It is caused by hypertrophy of the pylorus. Diagnosis is confirmed with an ultrasound. The buzzword that is typically used is "olive-like mass" in the right upper quadrant.

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Raloxifene should be avoided in women with a past history of thrombosis. Raloxifene does not increase the risk of endometrial cancer, unlike tamoxifen. The risk of breast cancer decreases with raloxifene use. There are no definitive data showing raloxifene modifies the risk of ovarian cancer. Raloxifene is a mixed agonist/antagonist of estrogen receptors, acting as an antagonist in breast/vaginal tissues and an agonist in bone. Raloxifene increases the risk of thromboembolism.

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Reaction formation is being demonstrated in this case. This occurs when a patient adopts the opposite attitude of personally unacceptable emotions for the purpose of avoiding them. Because of her unconscious resentment of having to move in with her elderly mother, the woman overcompensates by spending excessive time and money on the elderly. This is a classic scenario and should be recognized.

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Rib raising decreases sympathetic activity and improves lymphatic return by improving negative intrathoracic pressure. It is contraindicated in patients with recent spinal surgery, rib fractures, or spine fracture.

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The sphenopalatine ganglion is associated with parasympathetic activity in the upper respiratory system. In this case, the patient has sinusitis and is producing more copious, thicker secretions, which inhibits the parasympathetic nervous system. The sphenopalatine ganglion technique may help thin the patient's secretions and help clear his infection more expeditiously. Additional osteopathic considerations include rib raising to stimulate the sympathetic nervous system to produce thinner secretions and performing a generalized lymphatic treatment.

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Right upper quadrant pain, jaundice, and fever (Charcot triad) are classic findings of cholangitis. In acute suppurative cholangitis, patients will also present with hypotension and confusion (Reynolds pentad). Cholangitis is an infection within the common bile duct and most commonly results from a common bile duct stone or choledocholithiasis. The treatment of choice is NPO, broad-spectrum antibiotics, endoscopic retrograde cholangiopancreatography, sphincterotomy, and stone extraction on an urgent or emergent basis. This patient has RUQ pain, fever, and jaundice (Charcot's triad). Fever and right upper quadrant pain are consistent with all forms of viral hepatitis. This patient could have acute hepatic encephalopathy secondary to some kind of hepatic insult, given her RUQ pain, fever, and confusion, which would be a poor prognostic sign in acute liver failure as this is generally associated with cerebral edema. Reynolds pentad is a collection of signs and symptoms seen in ascending cholangitis and consists of fever, right upper quadrant pain, and jaundice (Charcot triad) plus shock and altered mental status. This patient displays the entire pentad.Acute cholecystitis can be considered in the differential diagnosis but would not be expected to cause jaundice. Alternatively, in patients with gallstones, they may have both common bile duct obstruction and cystic duct obstruction and can present with cholecystitis as well as other biliary abnormalities. Cystitis does not cause jaundice or sepsis. This is a term for a mild infection localized to the bladder. The patient's signs and symptoms are not consistent with pancreatitis, although pancreatitis can be seen along with biliary pathology (such as common bile duct gallstones). A perforated duodenal ulcer can cause fever, abdominal pain, tachycardia, and hypotension. It does not usually cause jaundice, but could, if there was damage to the common bile duct or obstruction due to abscess and inflammation.

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Roseola infantum is caused by HHV-6 and presents with high-grade fever lasting four days with an abrupt return to normal. This is followed by a diffuse maculopapular rash which first appears on the chest and abdomen.

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Salmonella may cause bloody diarrhea, but it is less likely than Shigella because it has a higher ID50 and is not associated with day-care outbreaks.

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Selenium deficiency is classically seen as Keshan disease in China, or in patients on total parenteral nutrition. Presenting features are skeletal muscle dysfunction, cardiomyopathy, mood disorders, impaired immunity, macrocytosis, and white nail beds.

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Selenium is a trace mineral with a narrow optimal range for dietary intake. The best sources are seafood, kidney, liver, and meat. Deficiency causes skeletal muscle dysfunction, cardiomyopathy, mood disorders, impaired immunity, macrocytosis, and whitened nail beds. Keshan disease is an endemic form of selenium deficiency in China seen in children and women of childbearing age. The geographic distribution reflects areas where diets are deficient in selenium. Selenium deficiency can also be seen in patients on total parenteral nutrition if there is no selenium supplementation. The recommended daily allowance is 20 mcg for children and 55 mcg for adults. Toxicity occurs quickly at levels of 5 mg/day, and presents with nausea, emesis, diarrhea, hair loss, nail changes, peripheral neuropathy, and mental status changes.

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Semicircular canals containing dislodged otoconia describes the pathophysiology of benign positional vertigo, which is generally not associated with hearing loss.

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Sepsis caused by Gram-negative bacteria is thought to be largely due to the host's response to the lipid A component of lipopolysaccharide, also called endotoxin.

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Septic arthritis is most commonly caused by Staphylococcus aureus. Children will typically have a fever and joint pain, most commonly in the knee. Physical exam will reveal an erythematous swollen joint. The condition is diagnosed by aspirating the joint fluid. Erythrocyte sedimentation rate can be used to monitor treatment. Septic arthritis is treated with antibiotics.

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Severe carpal tunnel syndrome (CTS) with signs of axonal damage on EMG is best treated with surgical release of the carpal tunnel. All other forms of CTS can be treated with conservative management first.

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She needs to be admitted for IV antibiotics, fluid resuscitation, and urology consult for possible lithotripsy vs. ureteral stenting. Discharging her home may be considered negligence.

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Sigmoid volvulus typically presents with colicky abdominal pain and abdominal distension and is a cause of large bowel obstruction. It would not be expected to cause such a dramatic picture unless the bowel was already dead. In general, the abdomen would be severely distended and tympanic. This patient has no signs of a bowel obstruction on exam.

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Slipped capital femoral epiphysis (SCFE) typically presents in obese teenagers as knee pain and a limp. On plain radiographs, the femoral head is seen displaced posteriorly and inferiorly in relation to the femoral neck and within the confines of the acetabulum. Treatment consists of surgical correction with screws.

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Slipped capital femoral epiphysis occurs in obese children who are active and between 10 and 15 years old. Patients will typically complaining of aching pain in the hip, knee, or thigh. Pain is worse with activity. X-ray reveals the "ice cream falling off a cone" finding. This is a Salter-Harris type I fracture through the physis. Treatment consists of surgical pinning.

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Status epilepticus refers to the occurrence of a single unremitting seizure with a duration longer than 5 to 10 minutes or frequent clinical seizures without an interictal return to the baseline clinical state. This syndrome can be seen in patients who progress to eclampsia.

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Sturge-Weber syndrome is a noninherited congenital condition. Patients present with a congenital port wine stain in the distribution of the V1 and V2 trigeminal nerve. The condition is associated with epilepsy, eye abnormalities including glaucoma, intellectual disability, and hemiatrophy. The port wine stain is a pink to red patch overlying the forehead and eyelids and is most commonly unilateral.

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Suboccipital release is a soft tissue technique used for reducing musculature and soft tissue tension of the cervical spine. It is used primarily to improve tension headache pain, as well as for forward head posture.

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The superior rectus muscle, also innervated by the oculomotor nerve (cranial nerve III), moves the eye into upgaze; however, due to the fact that inferior floor fractures are the most common site of orbital fracture, it is unlikely to be involved. Orbtal roof fractures are uncommon. Typically, the superior rectus muscle is not involved in these types of injuries. The reason that the eye cannot look up has nothing to do with the superior rectus muscle. It is because the globe is unable to rotate superiorly due to the attachment of the inferior rectus muscle (which is now entrapped between bone), which holds the eye in place.

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Succinylcholine is a depolarizing neuromuscular blocker with 2 phases. The depolarizing action can cause fasciculations (twitching), particularly in muscular patients. Phase 1 is the primary paralytic effect, and involves keeping the membrane potential above threshold so that it is constantly depolarized. Phase 2 involves a non-depolarizing blockage, where acetylcholine is competitively antagonized. Succinylcholine onset is rapid, biphasic, and has no refractory period. An important side effect is hyperkalemia due to increased cellular potassium efflux. Due to the risk of cardiac arrest from hyperkalemia, succinylcholine is contraindicated in burns, crush injuries, known hyperkalemia, and neuromuscular disease. Succinylcholine is also associated with malignant hyperthermia, which involves muscle rigidity and increased temperature after induction. Malignant hyperthermia is treated with dantrolene. Sugammadex is a reversal agent for non-depolarizing neuromuscular blockers, recently approved by the Food and Drug Administration (FDA), that may make succinylcholine obsolete in the future. Until then, succinylcholine will be used in nearly every major surgery.

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Superficial vaginal pain during sex in the setting of normal menstrual periods and a normal pelvic exam is likely due to a lack of lubrication.

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Suspect Meniere's disease in patients who present with episodes of hearing loss, tinnitus, and vertigo. Patients may report an abnormal sensation of pressure or fullness in the ears, as in the case above.

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Suspect lung cancer in a patient with unintentional weight loss, cough, and smoking history. Remember that disease may be advanced at the time it is discovered, and this will affect treatment options. The current standard of care in the management of low-risk patients with locally advanced, unresectable (stage IV) non-small-cell lung cancer is platinum-based chemotherapy in conjunction with radiation therapy.

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Suspect secondary hypoadrenalism due to steroid withdrawal in postoperative patients who suddenly develop hypotension, shock, and hyperkalemia. Immediate treatment with corticosteroids should be performed if this diagnosis is suspected, even if it has not been confirmed. Dexamethasone does not interfere with serum cortisol assay and, thus, may be the initial drug of choice. However, because dexamethasone has little mineralocorticoid activity, fluid and electrolyte replacement are essential as well.

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Systemic lupus erythematosus (SLE) is a multisystem autoimmune disorder involving a variety of autoantibodies affecting several body systems. An antibody-mediated cellular attack occurs with deposition of antigen-antibody complexes in affected tissues. Some of the common findings on physical exam are malar and discoid rashes, serositis, oral ulcers, arthritis, photosensitivity, central nervous system symptoms (psychosis, seizures, strokes), and renal insufficiency. In addition, the patient can experience fevers, malaise, abdominal pain, and weight loss, as well as blindness or conjunctivitis.Lupus is diagnosed using the American College of Rheumatology criteria. A person can be diagnosed with SLE if he or she has 4 out of 11 noted symptoms present simultaneously or serially on 2 separate occasions. A useful mnemonic for remembering the diagnostic findings or symptoms of SLE is SOAP BRAIN MD (S = serositis; O = oral ulcers; A = arthritis; P = photosensitivity, pulmonary fibrosis; B = blood cells (cytopenias); R = renal disease, Raynaud; A = antinuclear antibody; I = immunologic [anti-Sm, anti-dsDNA]; N = neuropsychological; M = malar rash; D = discoid rash). These are not in order of diagnostic importance.

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The Food and Drug Administration (FDA) risk classification of pharmaceuticals include pregnancy categories defined as A-X, with classification based on studies conducted in both animal and human populations.Category A: Adequate and well-controlled studies have failed to demonstrate a risk to the fetus in the first trimester of pregnancy (and there is no evidence of risk in later trimesters).Category B: Animal reproduction studies have failed to demonstrate a risk to the fetus, and there are no adequate, well-controlled studies in pregnant women or animal studies that have shown an adverse effect, but adequate, well-controlled studies in pregnant women have failed to demonstrate a risk to the fetus in any trimester.Category C: Animal reproduction studies have shown an adverse effect on the fetus, and there are no adequate, well-controlled studies in humans, but potential benefits may warrant the use of the drug in pregnant women despite the potential risks.Category D: There is positive evidence of human fetal risk based on adverse reaction data from investigational or marketing experience or studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks.Category X: Studies in animals or humans have demonstrated fetal abnormalities and/or there is positive evidence of human fetal risk based on adverse reaction data from investigational or marketing experience, and the risks involved in use of the drug in pregnant women clearly outweigh the potential benefits.

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The above case represents a teenager presenting with elevated transaminases with an AST to ALT ratio of 2:1 which suggests alcohol abuse. The case also informs you that this is a teenager who skips school, suggesting reckless behavior, which should increase the suspicion of substance abuse. Multiple screening tools have been established to detect at-risk individuals and can be performed quickly and non-invasively. One of the most commonly used screening tools is known as the CAGE questionnaire and utilizes the following questions: Have you ever felt the need to Cut down on drinking? Have you ever felt Annoyed by criticism of your drinking? Have you ever had Guilty feelings about your drinking? Do you ever take a morning Eye-opener (a drink first thing in the morning to steady your nerves or get rid of a hangover)? A positive response to any CAGE question suggests the need for closer assessment, and a positive response to two or more has a sensitivity of 77% and over 80% specificity for detecting alcohol dependence.

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The anterior cruciate ligament (ACL) is the most commonly injured knee ligament. Aside from direct trauma, nearly all ACL tears occur from noncontact athletic injuries. Female gymnasts sustain the highest rate of injury (0.33 ACL injuries/1000 athletic exposures). There are currently 5 proposed explanations to account for the gender disparity involving ACL tears, as women sustain significantly higher rates than men, which are: quadriceps-dominant deceleration, increased valgus knee angulation, effects of estrogen, discrepancies in Q angle, and decreased intercondylar notch width. The most sensitive and specific tests to delineate ACL injury are the Lachman, the pivot shift, and the anterior drawer test.

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The brachioradialis originates at the lateral condyle of the humerus and inserts onto the styloid process of the distal radius. It serves to flex the forearm. The brachioradialis has no attachment to the lateral epicondyle.

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The cerebellum is the portion of the brain that is responsible for coordination, muscle tone, posture, and control of voluntary movements. The finger-to-nose test is part of the neurologic assessment that can help localize a symptom to the cerebellum. It is tested by having the patient touch your finger (index finger) and then touch his or her nose. It is important to have the patient's arm fully extended during the exam to assess for ataxia or dysmetria. This patient is at risk for stroke, given the history of atrial fibrillation without anticoagulation, older age, and previous history of stroke. If the cerebellum is affected during an ischemic event, patients often report symptoms of vertigo, dysarthria (which is generally a motor ataxia of the tongue and vocal muscles), and lack of coordination. On exam, an abnormal finger-to-nose test is often present. Other findings on the neurologic exam used to localize a lesion or disease to the cerebellum include an abnormal heel-to-shin test, an abnormal gait, dysdiadochokinesis, dysmetria, intention tremor, scanning speech, and nystagmus.Definitions to know: Dysdiadochokinesis is difficulty with coordinating rapid, alternating movements, such as having a patient rapidly attempt to pronate and supinate the hand. Intention tremor gets worse the closer the finger is to the object trying to be touched Dysmetria is inability to judge distance Scanning speech is slow, slurred speech caused by oral motor ataxia

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The classic electrocardiogram (ECG) in acute pericarditis can evolve through 4 stages, and the timing of each of these stages can be highly variable. The 4 stages of ECG changes in patients with acute pericarditis include:Stage 1: seen in first hours to days, diffuse ST elevation (typically concave up) with reciprocal ST depression in leads aVR and V1. There is also elevation of the PR segment in lead aVR and depression of the PR segment in the other leads.Stage 2: normalization of the ST and PR segments.Stage 3: development of diffuse T-wave inversions, generally after the ST segments have become isoelectric.Stage 4: normalization of the ECG. This can occur directly from stage 1 in self-limited cases or as a response to medical therapy.It is important to recognize that pericarditis does not always result in these changes. Many patients normalize without going past stage 1. Atypical ECG changes can be seen in up to 40% of patients with acute pericarditis.

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The classic presentation of rubella includes low-grade fever, malaise, and post-auricular lymphadenopathy followed by a maculopapular rash that begins on the face.

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The clinical scenario does not really give a definitive diagnosis. After review of the exhibit, a unilateral pleural effusion should be a clear finding. Opacity on a radiograph must be blood, pus, cells, or water. The question stem does not give a suggestion of blood or pus, and the most likely etiology is an effusion. The only helpful history is that of long-standing tobacco abuse. A unilateral pleural effusion is concerning in a patient without a history of pleural effusion or a rheumatoid disease. Typically, laboratory evaluation of the fluid is needed to determine if it is a transudate, exudate, or lymphatic in origin. This patient's smoking history places him at risk for neoplasm, and a malignant pleural effusion would be high on the differential. Please see the flowchart below. Typical radiographic findings of pleural effusion include blunting of the involved costophrenic sulcus, a meniscus sign, and if large enough, complete opacification of the lung field. An indication for thoracentesis is the new finding of a pleural effusion, especially unilateral. Observation, instead of diagnostic thoracentesis, may be warranted in uncomplicated heart failure and viral pleurisy. In the former setting, the clinical diagnosis is usually secure. In the latter, there is typically a small amount of fluid. However, if the clinical situation is atypical or does not progress as anticipated, thoracentesis should be performed. This patient is significantly symptomatic, and thoracentesis will be both diagnostic and therapeutic. Viscerosomatic reflexes are a type of somatic dysfunction caused by changes in the autonomic nervous system. They can be acute or chronic and are considered to be a somatic representation of visceral disease. When either branch of the autonomic nervous system (sympathetic or parasympathetic) overstimulates a particular organ, a reflex reaction occurs. The soma at the same level of the organ's autonomic innervation takes on characteristics of somatic dysfunction (TART). T2-T7 on the right is where the sympathetic viscerosomatic reflex for the right pulmonary system is located.The osteopathic findings described also illustrate acute findings in somatic dysfunction, versus chronic changes. Acute and chronic somatic dysfunction findings differ in tissue texture changes, restriction, and tenderness. Acute tissue texture changes are edematous and erythematous, with increased tonicity of muscles. The restriction is present and is painful with movement. Acute tenderness is described as severe and sharp. In patients with chronic somatic dysfunction, the tissue texture changes are cool, dry, flaccid, ropy, and fibrotic. The restriction is present, but there is decreased or no pain. Tenderness in chronic somatic dysfunction is described as dull, achy, and burning.

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The correct answer is hyperkalemia and hyponatremia. This patient presentation can be summarized as a young woman who is chronically lethargic and hyperpigmented who presents with borderline hypotension after a GI illness. This presentation is consistent with Addison disease--a disorder that is commonly autoimmune in nature (hinted at with the reference to vitiligo)--and results in diminished secretion of both cortisol and aldosterone. It commonly goes undiagnosed until signficant demand is put on the adrenal system with something like concurrent viral/bacterial infection leading to shock and circulatory collapse and subsequent hospitalization. The electrolyte abnormalities are multifactorial in nature. Hyponatremia is most significantly affected by decreased cortisol levels, which leads to general vasodilation/hypotension and increased anti-diuretic hormone secretion with a result of water retention and decreased plasma sodium concentration. In addition, corticotropin releasing hormone is also an ADH secretagogue. Hyperkalemia, in contrast, is due almost entirely to aldosterone deficiency as its primary effect is excretion of potassium in the urine with the retention of sodium. The bronze effect seen is secondary to increased melanocyte stimulating hormone, which is a byproduct of ACTH production.The evaluation of patients with suspected Addison disease should always include an electrolyte panel to test for hyponatremia and hyperkalemia. Hyponatremia is the most common finding and occurs in 90% of patients. Hyperkalemia is also common and can occur in up to 70% of cases. Hypercalcemia is uncommon but is still found in up to 10% of patients presenting with the disorder.

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The diagnosis of endocarditis can be made using the modified Duke Criteria. These are included below for reference and generally, include both clinical and pathological criteria. In most cases, only the clinical criteria are used as the pathological criteria require biopsy and culture of a vegetation from a valve. These criteria can be used when cardiac surgery is performed, however, by that time, most patients will have already met the clinical criteria. The clinical criteria are listed below. The pathological criteria are met if either of these is done: vegetation or intracardiac abscess confirmed by histology or culture of a vegetation (from the heart or embolized) or intracardiac abscess. Clinical Duke CriteriaMust meet one the following: 2 major clinical criteria 1 major and 3 minor criteria 5 minor criteria Major Criteria: Defined Bacteremia: 1. Known organisms are known to cause endocarditis from 2 separate blood cultures Staph aureus, Strep viridans, Strep Bovis, HACEK OR2. Two positive blood cultures drawn at least 12 hours apart OR3. Coxiella burnetii positive, by titers or blood cultures only 1 is needed (unlikely to be tested) Heart Involvement:1. Echo shows a mass/vegetation around the mitral valve OR2. Echo shows abscess OR3. New valvular murmur, prosthetic valve dehiscence Minor Criteria: IV drug use or previous heart condition (congenital heart disease or valvular replacement) Fever > 38°C Vascular phenomena: arterial emboli, septic infarcts, mycotic aneurysms, Janeway lesions, intracranial hemorrhage Immune-mediated glomerulonephritis, Osler nodes, Roth's spots (in eyes) Bacteremia: Only if it does not meet major criteria excepting organisms that do not usually cause endocarditis or are usually contaminants, such as coagulase-negative staph The patient has a systolic heart murmur consistent with mitral valve regurgitation, Janeway lesions, fever, persistent bacteremia, and a history of IV drug use, which meets 1 major and at least 3 minor criteria for acute infective endocarditis.

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The diagnosis of hemochromatosis is made significantly more likely if laboratories show an increased serum iron level, increased percent saturation of iron, increased ferritin, and decreased serum transferrin levels. The transferrin saturation (Tsat) level is calculated by dividing the serum iron by the transferrin level and is generally considered the most sensitive diagnostic test. At one time, it was felt that this test needed to be performed while fasting; however, diurnal variation is minimal and fasting is no longer felt to be necessary. The physiology of iron storage dictates the changes in laboratory values. As serum ferritin is directly related to stored iron, in hemochromatosis, serum ferritin rises. Transferrin is inversely related to stored iron because its levels increase in response to iron deficiency to help transport absorbed iron from the gut. At the same time, as total body iron rises, serum iron levels also rise, increasing the bound fraction of transferrin.The reason that none of these tests are highly specific for hemochromatosis is that ferritin, transferrin, and iron all respond to changes in inflammation through the action of hepcidin. Many patients with chronic inflammatory conditions will have high serum ferritin but no evidence of hemochromatosis, even with ferritin levels >1000 mg/dL. The finding of high serum ferritin with high Tsat does modestly increase the likelihood of diagnosing hemochromatosis; however, it is now recognized that these measurements alone will not diagnose all cases of hemochromatosis, especially in younger patients, with high accuracy.

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The diagnostic criteria for acute stress disorder include experiencing a traumatic event and responding with such fear and horror that it significantly impairs the patient's ability to function. Nightmares, flashbacks, being easily startled, and the inability to do anything that may remind the person of the event are all common symptoms. The main way to distinguish this from posttraumatic stress disorder (PTSD) is timing. For acute stress disorder, the disturbance lasts for a maximum of 4 weeks, whereas PTSD can last for years. While the symptoms of PTSD and acute stress disorder are essentially the same, patients with acute stress are more likely to experience the numbing, dissociative symptoms immediately after the traumatic event.

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The effects of excessive ibuprofen or naproxen, both nonsteroidal anti-inflammatory drugs (NSAIDs), could include nausea, dyspepsia, gastrointestinal ulceration/bleeding, elevated liver enzymes, diarrhea, epistaxis, headache, and dizziness. Renal involvement is also a prominent feature but may be asymptomatic early on. Although rarely tinnitus has been associated with NSAID use, it is notable that in some of these published reports NSAIDS were co-ingested with aspirin. The latter has an established relationship with tinnitus even at therapeutic doses and is therefore much more likely to be responsible for the constellation of symptoms in this patient.

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The electrocardiogram reveals torsades de pointes. This is ventricular tachycardia with a characteristic twisting of the QRS waves. It has been associated with a fall in arterial blood pressure, resulting in syncope. Congenital long QT syndrome is a rare inborn heart condition that results in delayed repolarization of the heart due to mutations of the ion channels carrying the cardiac impulse potential. This increases the risk of episodic torsade de pointes. These episodes lead to palpitations, syncope, and most seriously, sudden death due to ventricular fibrillation. Torsades de pointes can also develop as a result of electrolyte loss from diarrhea, hypomagnesemia, and hypokalemia. Furthermore, there are various medications that cause QT prolongation, which include but are not limited to amiodarone, methadone, lithium, chloroquine, erythromycin, procainamide, and phenothiazines.Treatment for long QT syndrome includes beta-blockers to inhibit the adrenergic impulse to the heart. Medications that prolong the QT segment should be avoided.Treatment for torsades de pointes depends on the stability of the patient. Unstable patients require prompt treatment with electrical cardioversion/defibrillation. They may also be given intravenous (IV) magnesium. For stable patients who had a single episode of torsades, treatment with IV magnesium along with correction of metabolic/electrolyte derangements and/or removal of any inciting medications may be sufficient. For stable patients with multiple episodes, the prior mentioned interventions can be used; additional interventions to regularize the heart rate, such as overdrive atrial pacing and/or IV isoproterenol infusion, may be required.

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The first step in an advanced cardiac life support (ACLS) scenario is to check the CAB (circulation, airway, and breathing). This patient is in pulseless electrical activity (PEA). It is not a shockable rhythm. According to ACLS, you should continue cardiopulmonary resuscitation (CPR) for at least 2 minutes, and then you need to perform both a rhythm and pulse check. If the rhythm is shockable, you would proceed with defibrillation. If the patient is still in PEA, you would continue with CPR, administer epinephrine, and begin to consider possible causes. Epinephrine can be given every 3 to 5 minutes. You must perform a pulse check and rhythm check every 2 minutes for no more than 10 seconds.You should consider causes for PEA, including Hs and Ts. Hs include hypovolemia, hypoxia, acidosis, hypo-/hyperkalemia, and hypothermia. Ts include toxins, cardiac tamponade, tension pneumothorax, thrombosis including myocardial infarction and pulmonary embolism, and trauma.

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The ice pack test is a rapid physical exam test performed at bedside. It is useful for patients with ptosis but has no effect on extraocular muscle weakness. Neuromuscular transmission improves at lower temperatures. In the test, after ice is placed on a closed lid for 2 minutes, it is removed. If improvement of ptosis occurs, this is interpreted as a positive test result. The sensitivity is near 80%; however, interpretation is subjective, and improvement may be seen in individuals without MG. Additionally, this test is of no value in patients with MG without ptosis.

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The most appropriate course of action in this situation is to give whole blood. COMLEX likes to test the point that you should never withhold lifesaving treatment from a child, regardless of the parents' wishes. Additionally, in emergent situations when a parent cannot be reached, consent is implied for minors.

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The time course and severity of neonatal conjunctivitis is important for prognosis and treatment. Chlamydial and herpetic infections often present at 5-14 days, while gonococcal infections present between 2-5 days and are associated with a more severe course. Chemical conjunctivitis appears during the first day of life, and management is reassurance.

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The most appropriate treatment option in this scenario is to intubate the patient and place her on mechanical ventilation. Because the patient is unresponsive and lacks an advance directive, there is no way to know what she would prefer in this situation. Even though she may have had a conversation with her friend regarding her end-of-life, there is no way to validate these wishes. Also, mechanical ventilation may be a temporary measure, and the patient may only require it for a short amount of time. Osteopathic Pearl: Rib dysfunctions are a type of somatic dysfunction in which movement or the position of a rib is altered or disrupted. This can be seen with a single rib, or it can be a group dysfunction. In a group dysfunction, there is usually one rib that is responsible for causing the dysfunction, referred to as the "key rib". This particular case is describing an exhalation dysfunction. In an exhalation dysfunction, the dysfunctional rib(s) will move caudad during exhalation, however the dysfunctional rib(s) will not move cephalad during inhalation. The rib will appear to be "stuck down." In ribs with bucket handle motion (ribs 6-10) there will be lateral narrowing of intercostal space below the dysfunctional rib in an exhalation dysfunction. Lastly, in a group exhalation dysfunction, the key rib is the uppermost rib (in this case, rib 6 on the right).

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The most common cause of death in the first few days following a myocardial infarction is ventricular arrhythmia. Beta-blockers have been shown to decrease the occurence of ventricular arrhythmias in ST-segment elevation myocardial infarction (STEMI) patients. The routine use of antiarrhythmic drugs (lidocaine, amiodarone) to suppress premature ventricular contractions after STEMI is NOT helpful and can actually be harmful. Typically, mechanical complications of myocardial infarction occur in patients who present >12 hours from symptom onset.

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The most common nontraumatic cause of mechanical or extraocular muscle-related binocular diplopia in adults is thyroid eye disease. Although thyroid eye disease usually occurs in the setting of a hyperthyroid state, it may occur with hypothyroid or euthyroid status and runs an independent course from the underlying thyroid. Acute thyroid eye disease is characterized by inflammatory infiltration of the extraocular muscles and orbital structures with deposition of hydrophilic glycosaminoglycans, producing extraocular muscle scarring. Clinically, thyroid eye disease presents with painless proptosis, restrictive ophthalmoparesis, and eyelid retraction.

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The most common type of dislocation is an anterior shoulder dislocation; therefore, the most likely injury sustained is to the axillary nerve, which causes loss of sensation in a "shoulder badge" distribution.

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The most commonly elevated enzymes in cases of dermatomyositis are creatine kinase and aldolase. These enzymes spike secondary to muscular breakdown and are elevated in the majority of cases. Creatine kinase, in particular, has been shown to be the most sensitive and specific enzyme for this disorder. Several other laboratory values can be abnormal such as antinuclear antibodies (ANA), aspartate aminotransferase, lactate dehydrogenase (LDH), and myositis-specific antibodies (MSAs), such as anti-Mi-2 and anti-Jo-1, but they are not specific to dermatomyositis.

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The most likely cause of this patient's presentation is injury to the axillary nerve. The axillary nerve courses around the posterior aspect of the humeral head and is the most common nerve injured in anterior/inferior shoulder dislocations. An anterior shoulder dislocation is usually caused by a blow to the abducted, externally rotated, and extended arm. The anterior/inferior dislocation can stretch the axillary nerve, thus injuring it. Some degree of axillary nerve dysfunction is present in 42% of patients with an anterior dislocation, but most patients recover completely without any interventions. The axillary nerve gives motor innervations to the deltoid, the teres minor, and the long head of the triceps, and so you may see weakness in these muscles. Specifically, the deltoid is the main muscle responsible for abduction after the first 15 degrees. Typical deep tendon reflexes that are tested in upper extremities are biceps, triceps, and brachioradialis reflexes. Injury to the axillary nerve will not affect these reflexes.

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The most likely diagnosis based on this case is an anterior shoulder dislocation after trauma. The axillary nerve is most likely injured in an anterior dislocation of the shoulder, which is much more common than a posterior dislocation. Anterior shoulder dislocations may be caused by a direct blow to an abducted shoulder, as is the case in contact sports such as football and ice hockey. The patient may present with shoulder pain and a slightly abducted, externally rotated arm. Posterior dislocations are less common but more serious and are commonly caused by seizures or electrocutions. Axillary nerve damage will cause inability to abduct the shoulder during the initial 15 degrees of motion. Treatment of shoulder dislocations is with reduction; complications of instability and concomitant injury to surrounding structures aren't uncommon.

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The most likely diagnosis for this patient is spondylolysis or spondylolisthesis. Spondylolysis is a unilateral or bilateral defect (fracture or separation) in the vertebral pars interarticularis, usually in the lower lumbar vertebrae. Spondylolisthesis occurs when bilateral defects develop, the vertebral body may slip anteriorly relative to the subadjacent vertebra. Spondylolysis presents with insidious low back pain. The primary symptom is low back pain during activities, particularly those involving lumbar extension. Pain is generally centralized in the midline but can radiate into the buttocks. With spondylolisthesis, the pain is usually more severe and can present with neurologic signs such as paresthesias and/or pain radiating to the buttocks or thigh.Included in the differential is apophysitis. Common places in the spine for apophysitis are superior and inferior endplates of vertebral bodies (ring apophysitis) and at the iliac crest. Tenderness over these areas in a growing athlete with an otherwise normal workup suggests apophysitis.Lordotic low back pain must also be included. Gymnasts are known for standing with a hyper-lordotic posture. This is a mechanical back pain that must be considered if the work-up is otherwise negative.Sacroiliac (SI) dysfunction is another differential. Athletes with any lumbar injury can develop atrophy of the lumbar extensor muscles due to pain inhibition and lack of using the muscles. This may result in some SI dysfunction, which can present with pain at the superior buttocks adjacent to the L5 region. Pain often increases with lumbar flexion as well as extension.

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The most likely diagnosis in this elderly man with lower urinary tract symptoms is benign prostatic hyperplasia (BPH). BPH is an enlargement of the prostate, which is a normal part of the aging process, and is seen in greater than 80% of men by age 80. It most commonly presents in men over the age of 50. BPH can result in urinary retention, recurrent urinary tract infections (UTIs), bladder and renal calculi, hydronephrosis, and kidney damage over time. It presents with obstructive or irritative symptoms. Obstructive symptoms include hesitancy, weak urine streams, intermittent urine stream, incomplete bladder emptying, urinary retention, and bladder fullness. Irritative symptoms include nocturia, daytime frequency, urge incontinence, and opening hematuria. BPH most commonly occurs in the transitional or periurethral zone of the prostate and may not be detected on digital rectal exam (DRE).

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The most likely diagnosis in this patient is De Quervain's disease. De Quervain's disease is also called stenosing tenosynovitis of the abductor pollicis longus (APL) and extensor pollicus brevis tendons, but more often, it involves the APL. It is a common overuse syndrome seen in construction workers and waitresses, is six times more common in females, and has been associated with rheumatoid arthritis. It presents with pain and tenderness at the radial styloid near the anatomical snuffbox. It can be diagnosed with Finkelstein's test, which is elicited by grasping the thumb and abducting the hand toward the ulna. A positive test shows extreme pain over the radial styloid. Conservative treatments with rest, activity modification, and splinting followed by corticosteroid injections are the mainstay and are successful in many patients. De Quervain's disease that is resistant to conservative treatment may be treated with surgery.

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The most likely diagnosis in this patient is a small bowel obstruction (SBO). Most SBOs resolve with conservative management. Surgery is indicated for refractory cases, perforation, strangulation, and necrosis. Rebound tenderness and guarding are signs of peritonitis, which could be caused by perforation of the bowel wall; therefore, surgery is warranted in these cases.

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The most likely diagnosis in this patient is a tension pneumothorax caused by the penetrating stab wound. A stab deep enough to go through the pleural membrane will cause accumulation of air in the pleural space. This can lead to increased thoracic pressure that compresses other thoracic structures and results in lung collapse. Collapse of the lung can impair ventilation and oxygenation. Compression of other structures, including the vasculature, will cause decreased venous return and a drop in cardiac output. This will then lead to obstructive shock, reflex tachycardia, hypotension and cardiac arrest if it is not treated. In the emergency department, it is important to perform a needle thoracostomy in an unstable patient to help relieve built up air. If a patient is hemodynamically unstable with a suspected tension pneumothorax as is described in the question stem, imaging is not necessary before intervening. The definitive treatment includes placement of a chest tube in the fifth intercostal space along the midaxillary line.Below is a plain film showing a right-sided pneumothorax. The arrow is pointing to the visceral pleural surface of the right lung. A pneumothorax under tension would have a similar appearance, only with shifting of mediastinal structures to the contralateral side (left) due to build up of air and increased thoracic pressure.

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The most likely diagnosis in this patient is acute hematogenous osteomyelitis of the tibia. Hematogenous osteomyelitis most commonly occurs in male children under the age of 12 years old. Osteomyelitis may be classified as acute, subacute or chronic based on the duration of signs and symptoms. It may also be classified as hematogenous or exogenous. Hematogenous osteomyelitis is the most common type seen in the pediatric population and is usually precipitated by a previous bacteremia. The metaphysis of the affected bone is most commonly implicated due to its rich blood supply. C-reactive protein is the most effective lab value for monitoring an early response to treatment because it normalizes much sooner than the erythrocyte sedimentation rate. CRP should be checked every 2-3 days after the initiation of antibiotic therapy. If no response to antibiotic treatment is noted within 24-48 hours, occult abscesses should be considered as the primary diagnosis and surgical debridement is recommended.

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The most likely diagnosis in this patient is subacromial bursitis which is a common cause of shoulder pain. It presents with shoulder pain that is often poorly localized, however it is sometimes present around the acromion. Patients complain of shoulder pain that is worst when doing overhead activities such as combing one's hair and may awaken the patient at night. Physical exam is usually benign but may show a positive Neer's impingement test. Neer's impingement test is performed with the patient in the sitting position. The patient's arm is forward flexed while the scapula is stabilized. Pain near the acromion is considered a positive test. Hawkin's test is also sensitive for detecting subacromial impingement and is elicited by abducting the shoulder to ninety degrees and internally rotating the arm. Pain near the acromion is considered a positive test.

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The vault hold is a craniosacral hand placement used for evaluation and treatment of strains at the sphenobasilar synchondrosis. The physician can use either a direct or an indirect method of treatment. Most commonly, an indirect method is used to balance membranous tension. Finger placement for the vault hold is as follows: Index finger: greater wing of the sphenoid Middle finger: temporal bone anterior to the ear Ring finger: mastoid region of the temporal bone Little finger: squamous portion of the occiput

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The most likely diagnosis in this patient is succinylcholine toxicity. Succinylcholine is a depolarizing paralytic agent that is degraded by the enzyme pseudocholinesterase. Pseudocholinesterase is synthesized in the liver. Metabolites include succinyl and choline, which are then excreted in the urine. In renal failure patients, hyperkalemia is a common occurrence, and succinylcholine results in an increase in serum potassium levels in normal subjects by 0.5 to 2 mEq/L. Given this fact, succinylcholine should not be used in this patient, as she already has an elevated potassium level, putting her at high risk for arrhythmias.Other adverse effects of succinylcholine toxicity include malignant hyperthermia, muscle pains, acute rhabdomyolysis with hyperkalemia, transient ocular hypertension, constipation, and changes in cardiac rhythm, including bradycardia and cardiac arrest. In patients with neuromuscular disease or burns, a single injection of succinylcholine can lead to massive release of potassium from skeletal muscles, potentially resulting in cardiac arrest. Conditions having susceptibility to succinylcholine-induced hyperkalemia are burns, closed-head injury, acidosis, Guillain-Barré syndrome, cerebral stroke, drowning, severe intra-abdominal sepsis, massive trauma, myopathy, and tetanus. In addition, the additive/synergistic effects of succinylcholine and an opioid, sedative, or anesthetic agent can lead to succinylcholine toxicity. In rare cases, acute rhabdomyolysis with hyperkalemia followed by ventricular dysrhythmias, cardiac arrest, and death have been reported in apparently healthy children and adolescents.

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The most likely diagnosis is a ruptured ectopic pregnancy given elevated β-human chorionic gonadotropin (β-hCG) and missed menstrual periods in the presence of hypotension and the exam findings of an acute abdomen. Fluid resuscitation should be instituted to manage shock. At the same time, emergent surgery is required for management of ectopic pregnancy in hemodynamically unstable patients, especially when rupture of ectopic mass is suspected based on signs and symptoms. These clues include pelvic or abdominal pain or evidence of intraperitoneal bleeding. If the ectopic pregnancy has ruptured, it can cause internal bleeding due to rupture of the feeding branches from the uterine and ovarian arteries, which if left unchecked will lead to hemorrhagic shock. If the pregnancy is small enough, a salpingectomy or salpingostomy can be considered. Obviously, saving the tube by making an incision and removing the ectopic gestation can result in a functioning tube after healing, although there is risk of adhesions. Removing the tube completely, though, will not completely impair fertility and can also be done if the pregnancy is especially large or the bleeding especially severe. Postoperatively, β-hCG is generally measured weekly until the level is undetectable in patients who have undergone salpingostomy only. In patients who have had a salpingectomy, if pathology is positive for a tubal gestation, then checking β-hCG levels is considered by many to be unnecessary.

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The most likely diagnosis is aortic regurgitation. Until recently, rheumatic fever was the most common cause of valvular disease in the United States; however, the leading cause is now mechanical degeneration. Aortic regurgitation can be divided into acute and chronic subtypes.Acute aortic regurgitation can be caused by infective endocarditis, aortic dissection, or chest trauma. Acute aortic regurgitation presents with the rapid onset of pulmonary edema, sometimes referred to a flash pulmonary edema, cardiogenic shock, and severe dyspnea.Chronic aortic regurgitation can be caused by valvular malformation, rheumatic fever, or connective tissue disorders such as Marfan syndrome. Chronic aortic regurgitation presents with insidious onset of dyspnea on exertion, orthopnea, and paroxysmal nocturnal dyspnea.Physical examination in patients with aortic regurgitation presents with a blowing diastolic murmur at the left sternal border with or without a mid-diastolic rumble which is referred to as an Austin-Flint murmur. The Austin-Flint murmur is due to blood flowing backwards through the aortic valve and hitting the anterior leaflet of the mitral valve and is a primary indication for valve replacement. Other physical exam signs in patients with aortic regurgitation include de Musset's sign, Corrigan's pulse, Quincke's pulse and Duroziez's sign. De Musset's sign is head bobbing that occurs with the heartbeat. Corrigan's pulse refers to bounding pulses and Quincke's pulse refers to a pulsating nail bed with elevation of the nail. These three signs are a result of widened pulse pressures that results in hyperdynamic circulation.

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The most likely diagnosis is aortoiliac occlusive disease, also known as Leriche syndrome. Leriche syndrome is a subtype of peripheral artery disease (PAD) that involves pathology of the aortoiliac arterial system. PAD occurs as the blood supply to the extremities becomes occluded as a result of atherosclerotic plaque accumulation. The lower extremities are more commonly affected than the upper extremities. The clinical signs and symptoms depend on which vessels are involved, the extent and rate of obstruction, and the presence or absence of collateral blood flow.Patients often present with intermittent vascular claudication, which is defined as reproducible leg pain that occurs with activity and is relieved with rest. As the disease progresses, pain occurs at rest and affects the distal extremities. Dorsal foot ulcerations may occur secondary to poor perfusion. Aortoiliac disease may present with typical signs and symptoms of PAD in addition to buttock claudication, decreased femoral pulses, and male impotence. The measurement of ankle and brachial (ABI) systolic blood pressures can provide objective evidence of atherosclerosis and support the diagnosis of PAD. Doppler ultrasound may be used to help identify stenosis and occlusion. Treatment of PAD and its subtypes involves controlling any underlying conditions such as diabetes, tobacco use, and hypertension. ASA, cilostazol, and thromboxane inhibitors may improve symptoms. Anticoagulants such as heparin, low molecular weight heparins, and warfarin may be used to prevent clot formation. Surgery or amputation may be used when medical treatment fails.

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The patient most likely has schizophrenia, which commonly presents in the late twenties or early thirties. Positive symptoms are those that most individuals do not normally experience but are present in people with schizophrenia. Positive symptoms include delusions; disordered patterns of thought; and tactile, auditory, visual, olfactory or gustatory hallucinations. Hallucinations are also typically related to the content of the delusional theme. Positive symptoms generally respond well to medication. This is because medications target these symptoms best. It can be treated with dopamine antagonists.Earlier age of onset of symptoms, no precipitating stressors, and negative symptoms lead to a poorer response to medical therapy. Negative symptoms include a flat expression or little emotion, poverty of speech, inability to experience pleasure, lack of desire to form relationships, and lack of motivation. These elements contribute more to a poor quality of life, functional ability, and burden on others than do positive symptoms. People with greater negative symptoms often have a history of poor adjustment before the onset of illness, and response to medication is often limited.

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The most likely diagnosis is discontinuation syndrome. Discontinuation syndrome can present with anxiety, ataxia, vertigo, fatigue, headache, insomnia, irritability, nausea, tremor, and vomiting. It is caused by an abrupt cessation of selective serotonin reuptake inhibitor (SSRI) use. Paroxetine and venlafaxine are two antidepressants with the highest risk of developing discontinuation syndrome. When stopping these 2 medications, a slow taper over several weeks is recommended.Answer A: A cerebral hemorrhage is unlikely in this patient. She has no risk factors and a normal neurologic exam.Answer C: Malignant hyperthermia is a life-threatening condition that can be caused by exposure to general anesthesia medications, such as succinylcholine, which is a depolarizing neuromuscular blocking agent. It presents with hyperthermia, hypertension, tachycardia, tachypnea, acidosis, and rhabdomyolysis. It can be treated with dantrolene.Answer D: Neuroleptic malignant syndrome (NMS) can be caused by exposure to antipsychotics, such as haloperidol. It presents with rigidity, myoglobinuria, autonomic instability, and hyperpyrexia. It can be treated with dantrolene, or dopamine agonists such as bromocriptine.Answer E: Serotonin syndrome may be caused by any combination of medications that lead to very high serotonin levels. Combining multiple SSRIs, high doses of SSRIs, or combining SSRIs with serotonin-norepinephrine reuptake inhibitors (SNRIs) or monoamine oxidase inhibitors (MAOIs) can lead to serotonin syndrome. It presents with hyperthermia, muscle rigidity, cardiovascular collapse, flushing, diarrhea, and seizures. It can be treated with cyproheptadine.Bottom Line: Discontinuation syndrome can occur from abrupt cessation of selective serotonin reuptake inhibitor (SSRI) use. It can be prevented by tapering the dosage of SSRIs.COMBANK Insight : Certain adverse effects can result from psychiatric medications such as neuroleptic malignant syndrome (NMS), serotonin syndrome, malignant hyperthermia, and discontinuation syndrome. Make sure you are familiar with the diagnosis and treatment of each of these conditions.For more information, see:

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The most likely diagnosis is laryngotracheobronchitis, also known as croup, which is common in infants and young children. Croup is an acute viral inflammatory disease of the larynx, primarily within the subglottic space. Pathogens include respiratory syncytial virus (RSV), influenza, adenovirus, and parainfluenza virus (most common). It usually presents with prodromal upper respiratory infection symptoms that are typically followed by a low-grade fever, mild dyspnea, hoarse voice, barking cough, and inspiratory stridor that worsens with agitation. Mild cases are treated on an outpatient basis with cool mist therapy and fluid replacement. Moderate cases may require supplemental oxygen, oral or intramuscular corticosteroids, or racemic epinephrine. Severe cases are best treated with hospitalization and racemic epinephrine.

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The most likely diagnosis is laryngotracheobronchitis, also known as croup. Croup is an acute viral inflammatory disease of the larynx, primarily within the subglottic space. It is diagnosed clinically, but an anteroposterior neck radiograph may show the classic steeple sign resulting from subglottic narrowing; however, this finding is neither sensitive nor specific.

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The patient has CNS depression, respiratory depression, vomiting, and pupillary constriction, all of which are typical of an opioid overdose. Naloxone functions to block opioid receptors and is used as an antidote to reverse narcotic overdose. Naloxone has shorter duration of effect than most opioids and multiple doses or a drip might be necessary if the patient has ingested large amounts of narcotics or opiates with very long half-lives, such as methadone. The patient is demonstrating the same symptoms of opioid overdose, and she needs additional dosing of naloxone to protect her from respiratory arrest. Naloxone may cause the patient to have withdrawal symptoms, such as anxiety, diaphoresis, stomach cramps, diarrhea, piloerection, and dilated pupils. Once a patient has required multiple doses of naloxone, they are generally placed on an IV infusion of naloxone and transferred to the intensive care unit for close monitoring.

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The patient in this scenario is experiencing a protraction disorder. Protraction is defined as a slow rate of cervical change less than 1.2 cm/h for the nullipara and less than 1.5 cm/h for the multipara. Arrest disorders consist of complete cessation of progress. Arrest disorders include secondary arrest of dilation (no progress in cervical dilation in more than 2 hours), arrest of descent (fetal head does not descend for more than 1 hour in nullipara and more than 0.5 hours in multipara), and failure of descent (no descent). The patient in this scenario is continuing to make slow progress. The most common cause of a protraction disorder is inadequate uterine activity. The patient described above is only experiencing contractions every 3 to 5 minutes while on oxytocin. Although external tocodynamometry can only evaluate the time interval between contractions, a contraction interval of 4 to 7 minutes is likely not sufficient to cause cervical change. Internal tocodynamometry via an intrauterine pressure catheter (IUPC) allows the physician to evaluate contraction interval and strength of contractions. An IUPC is frequently used when inadequate uterine activity is suspected owing to a protraction or arrest disorder. Once inadequate uterine activity is diagnosed with an IUPC, oxytocin is usually administered.

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The patient is a 66 yo male who has not been vaccinated in several years. It is important to know the different adult vaccines and when they are administered. The flu vaccine is indicated for all adults and should be given every year during the flu season. Flu season is October to April in the northern hemisphere. The vaccine is typically available starting in August or September. The Shingles vaccine is now recommended for adults over age 50. The newer vaccine (Shingrix) is given in two doses 2-6 months apart. It is much more effective than the older vaccine (Zostavax) that was not recommended until age 60 and was only given in 1 shot. Zostavax reduces the risk of developing shingles by 51% and post-herpetic neuralgia (PHN) by 67%, while Shingrix is more than 90% effective at preventing shingles and PHN. For healthy individual pneumonia, vaccines are indicated starting at age 65. According to the CDC, the recommended dosing is to give the patient PCV13 at age 65 and the PPSV23 one year later. If the PPSV23 is given by mistake first, the PCV13 can be given one year later. Both of these vaccines may be given earlier than 65 for certain medical conditions, but they are still repeated at age 65 starting with the PCV13. For Tetanus, the CDC recommends tetanus vaccination for all babies and children, preteens and teens, and adults. Tdap is recommended once with a Td booster every 10 years. Often in practice, Tdap is given every 10 years. Since it has been >10 years since this patient was vaccinated he would be due for this vaccination.

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The patient presents with new-onset palpitations. The electrocardiogram ECG) shown demonstrates Wolff-Parkinson-White (WPW) syndrome, which is caused by an extra electrical pathway between the atria and ventricles, also known as the bundle of Kent. This type of conduction abnormality is also called atrioventricular reentrant tachycardia (AVRT). The aberrant pathway is usually on the side of the ventricle, well away from the atrioventricular (AV) node, creating a distinct pathway for the flow of electrical current from the atria to the ventricles and then back up into the AV node to create a loop. This loop is spread out and generally causes depolarization from the lateral ventricular wall toward the center of the heart, leading to a prolonged QRS complex as seen in this patient. The characteristic ECG findings include a shortened PR interval and a delta wave, which is a slurred upstroke of the QRS complex caused by early depolarization. Any time that the PR interval is <120 milliseconds, there should be concern for an accessory pathway. The PR interval in this ECG is much shorter than 120 milliseconds, or 3 small boxes. If it is difficult to see, you can estimate by understanding that it is less than half of one large box. This ECG also clearly demonstrates a delta wave in multiple leads, as evidenced by the upsloping QRS complex. In addition, if you measure the QRS duration, you will notice that it is probably greater than 110 milliseconds, which is also indicative of an accessory pathway. As you remember, each small box on an ECG is 0.04 seconds or 4 milliseconds. Patients with WPW can also have changes to their ST segment and T waves. This is due to repolarization changes secondary to aberrant depolarization. Generally these changes will be opposite of the major QRS complex or discordant changes. Although some patients with this abnormal pathway may never experience symptoms, others may experience palpitations, dizziness, and lightheadedness. Rarely, sudden death occurs due to a rapid ventricular response and inability of the ventricle to pump blood effectively to the vital organs. The diagnosis is made by the ECG findings coupled with the clinical history. Treatment is based on symptoms and the underlying cause. Antiarrhythmic medications are used to slow AV conduction. Ablation therapy has been shown to be a viable alternative. Patients with WPW have these findings on a resting ECG and do not need to be tachycardic because a reentrant circuit is not always active. For the majority of the time, they will be in normal sinus rhythm with only the short PR interval and delta wave as evidence of their underlying disorder.

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The patient presents with the diagnostic findings of gestational trophoblastic disease, specifically hydatidiform mole. Uterine bleeding in the first trimester, uterine size greater than the gestational date, elevated serum B-hCG level,and a heterogeneously echogenic mass or "snowstorm" appearance on the pelvic ultrasound are seen in hydatidiform moles. There are two types of hydatidiform moles: complete and incomplete. A complete mole has a 46 XX or 46 XY karyotype, no fetal parts, and 2-5% convert to choriocarcinoma. An incomplete mole has a 69 XXY karyotype, fetal parts, and rarely converts to choriocarcinoma. Hydatidiform moles increase the risk of uterine rupture. Treatment is dilatation and curettage with monitoring of the B-hCG levels.

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The patient should be started on immediate antibiotics as the next step in management. Surgical consultation may be appropriate, but it would not precede initiation of antibiotics.

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The phrenic nerve consists mostly of motor nerve fibers needed for diaphragmatic contraction. In addition, it provides sensory innervation for many components of the mediastinum, pleura, and upper abdomen. In phrenic nerve injury, asymmetric elevation of the hemidiaphragm is often seen with absence of movement during respiration.

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The preferred pharmacologic therapy for postmenopausal women with osteoporosis is a bisphosphonate, which has been shown to be an effective therapy in slowing bone resorption. Most bisphosphonates are oral, readily available, and well tolerated. If patients have a history of gastric bypass, cannot sit upright, or have significant gastrointestinal upset or esophagitis with bisphosphonate therapy, then longer acting intravenous (IV) formulations can be considered, such as zoledronate (zoledronic acid).

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The presence of stool in the rectal vault is most consistent with the diagnosis of severe idiopathic chronic constipation. The etiology of idiopathic chronic constipation is often multi-factorial and can be secondary to slowed colonic transit time, outlet delay, or outlet dyssynergy. Idiopathic chronic constipation is a disease primarily found in women. It is also more prevalent in nonwhites; those over age 60; and individuals with little daily physical activity, low income, and poor education. Patients complain of infrequent defecation and/or excessive straining when defecating. Symptoms often fail to improve with fiber supplements or mild laxatives. Chronic constipation can result from peripheral or central neurogenic disorders, non-neurogenic disorders, or be idiopathic. Please see examples below:

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The principle of autonomy implies that an individual acts intentionally, with understanding, and without controlling influences. Autonomy in medicine does not simply mean allowing patients to make their own decisions, but obligates the physician to create conditions necessary for patients to make autonomous choices.

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The risk of developing a ventricular aneurysm is greatest 6 to 10 weeks after suffering an MI. It may present with signs of heart failure or a stroke. Emboli may form within the ventricular aneurysm, where they can break away from the myocardium and become systemic emboli.

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The risk of suffering a free wall rupture, interventricular septal rupture, or papillary muscle rupture is greatest 5 to 10 days after an MI because macrophages have degraded important structural components of the myocardium in an attempt to repair the damaged tissue.

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The shoulder pain in this scenario is most consistent with a presentation of supraspinatus tendinitis caused by impingement of the greater tuberosity beneath the acromion. Reproduction of symptoms by provocation of this impingement, as seen in the Hawkins test, supports the diagnosis of a supraspinatus tendinitis. Pain is often seen with active abduction of the arm between 60 to 120 degrees.Answer A: Biceps tendinitis typically produces pain in the anterior shoulder radiating to the biceps muscle, this diagnosis would be supported with a positive Speeds test or Yergasons test which act by stressing the biceps tendon and reproducing pain at the shoulder. Biceps tendinitis is often seen in conjunction with rotator cuff tear.Answer B: The shoulder pain in this scenario is most consistent with a presentation of supraspinatus tendinitis caused by impingement of the greater tuberosity beneath the acromion. Reproduction of symptoms by provocation of this impingement, as seen in the Hawkins test, supports the diagnosis of a supraspinatus tendinitis. Pain is often seen with active abduction of the arm between 60 to 120 degrees.Answer C: While this patient is at risk for developing a rotator cuff tear due to the repetitive stress at his shoulder joint, he would have also presented with a positive drop arm test - this would have indicated a diagnosis of rotator cuff tear.Answer D: Thoracic outlet syndrome presents with pain and paresthesias usually in the arm, forearm and hand due to compression of the neurovascular bundle at the thoracic outlet.Answer E: A positive sulcus sign would indicate a glenohumeral dislocation. Presentation of glenohumeral dislocation is usually secondary to trauma.Bottom Line: Supraspinatus tendinitis presents with tenderness by the tip of the acromion process as well as a Hawkins test and pain with abduction.

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The video exhibit demonstrates the Adson test, which is the loss of the radial pulse in the arm by rotating the head to the ipsilateral side with an extended neck following deep inspiration. It is sometimes used as a sign of thoracic outlet syndrome (TOS). TOS affects mainly the upper limbs, with signs and symptoms manifesting in the arms and hands. There are three different types of TOS: venous, neurogenic, and arterial. Neurogenic (nTOS) is from brachial plexus compression, venous (vTOS) is from subclavian vein compression, and arterial (aTOS) is from subclavian artery compression. The symptoms vary based on what is being compressed. Venous TOS accounts for about 3 percent of cases. It typically occurs in individuals who perform vigorous repetitive exertion of the upper extremities with the arms above shoulder level. Quick forearm fatigue is common. Swelling plus pain and cyanosis of the affected extremity; paresthesias in the fingers are common but are a manifestation of swelling in the hand rather than nerve compression. Upper extremity edema due to varying degrees of venous compression or overt deep vein thrombosis is the hallmark of vTOS. A painful, swollen, and blue arm, particularly when occurring after strenuous physical activity, could be the first sign of a subclavian vein compression related to an unknown TOS and complicated by thrombosis, the so-called Paget-Schroetter syndrome, or effort-induced thrombosis.Neurogenic TOS accounts for most cases of TOS. Symptoms include pain, dysesthesia, numbness, and weakness, which may not be localized in specific peripheral nerve distribution. Symptoms are worsened by any activity that requires elevation or sustained use of the arms or hands. When present, symptoms include slowly progressive unilateral atrophic weakness of the intrinsic hand muscles that is more evident on the thenar aspect of the hand rather than the hypothenar aspect. There is no cyanosis or swelling associated with neurogenic TOS. Arterial TOS is almost always associated with a cervical rib or anomalous rib. It occurs in young patients without typical atherosclerotic risk factors distinguishing it from peripheral artery disease.Adson test can be used for all types of TOS. However, it is prone to false-positive results.

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These findings are most consistent with a small bowel obstruction. The clinical history reveals symptoms typically seen in small bowel obstruction, which consists of abdominal pain, nausea, and vomiting. In the review of the radiograph in the exhibit, multiple loops of air-distended small bowel are noted, which display mild thickening of the mucosa. Looking at the rectosigmoid, there is nearly no air density noted. This constellation of findings is very concerning for at least a partial small bowel obstruction, and further cross-sectional imaging should be obtained to identify a transition point.A small bowel obstruction occurs when the normal flow of intestinal contents is interrupted for a variety of reasons. The most common include adhesion formation, hernia, and, less commonly, small bowel tumors. Obstruction progresses with dilation of the proximal bowel and stomach with decompression of the bowel distal to the obstruction site. Symptoms include abdominal pain and distension, nausea, vomiting, and obstipation. The consequence of obstruction is strangulation of bowel subsequent interrupted blood flow and necrosis. Dehydration is also a consequence. An approach to use when looking at an abdominal radiograph includes evaluation of the gas pattern, soft tissues, calcifications, and extraluminal air. Some use the saying, "mass, gas, stones, and bones." Remember that air will distend the haustra in a large bowel, which does not extend from wall to wall. In contrast, a small bowel will have valvulae conniventes, which represent the mucosal folds of the small intestine and appear from luminal wall to wall. This is useful when trying to discern a large from a small bowel on a radiograph.Plain film radiography is used as the initial evaluation of the abdomen in suspected cases of bowel obstruction. An abdominal film series consisting of an upright chest and upright and supine abdomen are obtained. The upright chest film will help to detect free air under the diaphragm. The upright abdominal film will allow the evaluation of multiple asymmetric air-fluid levels, which are commonly seen in small bowel obstruction. The supine abdomen film will force the intestinal contents to fill the lumen of the bowel so an accurate evaluation of the degree of distention is noted. Abnormal dilation of the small bowel is typically greater than 2.5 cm. A paucity of air in the rectosigmoid is a concerning finding, and the patient should be followed closely for developing or worsening small bowel obstruction. CT imaging is the next step in the workup of suspected bowel obstruction. Treatment is typically conservative with bowel decompression using an enteric tube or surgical to fix the mechanical obstruction.

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This colonoscopy image displays melanosis coli, a benign disorder of pigmentation of the wall of the colon often found incidentally on a colonoscopy that is caused by chronic use of anthraquinone laxatives including senna extract, aloe, frangula, and cascara. It is seen in this image as multiple brown, pigmented spots throughout the colon. Biopsy can show pigment within macrophages within the lamina propria. Classically, this has not been associated with an increased risk of malignancy; however, there is at least one case-control study showing possible increased risk of precancerous lesions.This patient is suffering from hemorrhoids and is likely taking senna to relieve constipation and ease pain associated with bowel movements. Chronic use of laxatives leads to melanosis coli, which can develop as early as 4 months after starting regular laxative use and may resolve 6 to 12 months following discontinuation of laxatives. Patients are asymptomatic, and findings occur incidentally on a colonoscopy. The use of anthraquinone laxatives may cause discoloration of the urine as well. Other complications of chronic laxative use include colonic denervation and atony, constipation, and electrolyte and nutritional disturbances.

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This elderly patient has bacterial meningitis as indicated by the lumbar puncture results. For a patient at this age, empirical therapy must cover Streptococcus pneumoniae (covered by vancomycin), Neisseria meningitidis, (covered by ceftriaxone), and Listeria (covered by ampicillin).

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This is a classic example of the type of question seen on COMLEX. Knowing the risk factors for coronary artery disease are essential. The risk factors for heart disease include two categories which are uncontrollable and controllable. Uncontrollable risk factors include males over 45 years of age or females over 55 years of age, family history of heart disease in first degree relatives (by age 55 for male relatives and by age 65 for female relatives), post-menopausal, history of autoimmune conditions (SLE, RA) and race (African Americans, American Indians, and Mexican Americans are more likely to have heart disease than Caucasians). Controllable risk factors include smoking, high LDL, high triglycerides, low HDL, uncontrolled hypertension, illegal drug use, history of preeclampsia, physical inactivity, obesity (more than 20% over one's ideal body weight), uncontrolled diabetes, high C-reactive protein, and uncontrolled stress and anger.It is also important to know the CHD risk equivalents, which place you at the same risk of having a cardiac event as someone who has already experienced one. The conditions that are considered CHD risk equivalents are an abdominal aortic aneurysm, diabetes, peripheral vascular disease, chronic kidney disease, clinical coronary heart disease and carotid artery disease.The Framingham Risk Score is also very useful in stratifying patients at risk for a cardiovascular event. The scoring system is a sex-specific algorithm used to estimate the 10-year cardiovascular risk of an individual. See scoring systems online for more information.

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This is an adult male with anemia and a history of constipation, thus, it is important to screen for colon cancer. Anemia in an adult male is of gastrointestinal origin until proven otherwise. At this point, a colonoscopy is indicated to screen for colon cancer.

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This patient has dermatomyositis. The underlying cause is an inflammatory reaction in skeletal muscle. Muscle damage causes the release of creatinine, aldolase, and creatinine kinase from the muscle, which is then found in the serum. However, the definitive diagnosis is made via muscle biopsy. Management typically involves an initial use of high dose corticosteroids, tapered to lower doses for maintenance. Disease-modifying agents such as methotrexate may be used as well. true or false

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This is an incarcerated inguinal hernia, not a strangulated inguinal hernia. There are important differences to note and remember. Incarcerated hernias are irreducible, can cause obstruction, and be painful, but there are no associated signs of bowel necrosis. Things that would be concerning for strangulation would be significant and continued pain at the hernia site, signs of marked inflammation including sepsis with high fever, elevated WBC, obstruction, and the patient would generally appear toxic. Most of the time, strangulation would result in symptoms within hours given lack of intestinal blood flow and death. This patient's symptoms have been going on for days and are intermittent. The time course is too long for strangulation as he would have been toxic and likely dead by now if his hernia had been strangulated for days. The management of incarcerated hernias is reduction if possible; however, if not possible, then surgical management can be performed on a non-emergent basis as long as the hernia does not progress to strangulation. If there is a concern for developing edema around an irreducible hernia, then there is a higher risk for progression to strangulation. If the hernia in this example was not reducible by the emergency department physician, then more urgent surgical intervention would be an option, given his continued symptoms, but there is no need for an emergent trip to the OR at this time. The patient has no signs of sepsis and a normal serum lactate. He should be managed conservatively with an attempted reduction if possible. If a strangulated hernia is suspected then manual reduction is contraindicated as it could result in passage of necrotic bowl back into the abdomen. This patient currently has no pain, no signs of bowel necrosis or sepsis, and a manual reduction should be attempted. Labs are not needed in this patient unless you are concerned for strangulated bowel and the requirement for surgical management. Additional labs may be required if the hernia is not reducible. An EKG is not necessary for preoperative clearance in a healthy 33-year-old patient. If this patient's hernia was strangulated, it would be an emergent visit to the OR under the threat of life, and preop medical consultation is not recommended in that situation as the risk of delay outweighs the benefits of immediate surgical intervention. The patient's heart rate of 105 is likely related to pain and anxiety regarding his medical condition and will likely improve with pain medication and fluids. An immediate EKG is unnecessary.

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This is the appropriate answer. This patient had a massive PE requiring thrombolysis. She is at high risk for recurrence, especially if she remains non-ambulatory, and should be anticoagulated for at least three months given this was a provoked event and possibly longer if she continues to have significant risk factors. If this was a minor, segmental or subsegmental, provoked PE in an otherwise healthy patient with no other risk factors, then 3 months of anticoagulation alone could be considered with minimal follow-up. Of note, as the guidelines have evolved and anticoagulation has become safer, they have continued to lean more heavily towards longer and more continuous anticoagulation. This is true of both PE and DVT as with the newest changes to the CHEST guidelines, even distal DVTs can be considered for anticoagulation.

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This patient has Crohn disease, which is an inflammatory bowel disease that most commonly affects the distal ileum but may affect anywhere from the mouth to the anus. The disease spares the rectum and presents randomly throughout the GI tract with areas of involvement and normal tissue, known as skip lesions. Barium swallow will reveal this as "string sign." Gross morphology reveals transmural inflammation. Patients present with abdominal pain, weight loss, and diarrhea that may or may not be bloody. Physical exam includes oral aphthous ulcers, fistulas, fissures, ulcerations, and abscesses. Biopsy will reveal noncaseating granulomas and lymphoid aggregates. Complications include strictures, fistulas, perianal disease, malabsorption, and nutritional depletion. Chronic treatment of Crohn disease with colonic involvement is most commonly with sulfasalazine or mesalamine.In contrast to Crohn disease, ulcerative colitis presents with continuous colonic lesions and always involves the rectum. Gross morphology involves mucosal and submucosal inflammation. Additionally, friable mucosal pseudopolyps with mesentery hanging freely may be present. Imaging typically reveals a "lead pipe" appearance. Histology reveals crypt abscesses and ulcers. Complications include severe stenosis, toxic megacolon, and a higher incidence of colorectal carcinoma. Patients present with bloody diarrhea and abdominal pain. Conditions associated with ulcerative colitis include pyoderma gangrenosum and primary sclerosing cholangitis.

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This patient has Reynolds pentad, consisting of fever, jaundice, right upper quadrant (RUQ) pain, altered mental status, and signs of shock. All of these together are most concerning for ascending cholangitis, which is an infection of the biliary system. Some patients may present only with Charcot triad, which includes abdominal pain, jaundice, and fever. Generally, the biliary system prevents ascending infection through continued drainage and closure of the sphincter of Oddi. Sometimes, patients may develop biliary obstruction, leading to stasis and subsequent infection, as is often the case in choledocholithiasis. Other patients presenting with cholangitis may be predisposed to infection due to severe illness, which can cause biliary sludging, or due to an immunocompromised state. Ascending cholangitis is a serious illness and can lead to significant morbidity and mortality if not appropriated treated.

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This patient has Wilson disease, which is an autosomal recessive inherited disease in which the liver cannot synthesize ceruloplasmin. Ceruloplasmin is a protein that the body uses to excrete copper. Therefore, a deficit of this protein leads to a copper overload. This can affect many organs, but the most common organs affected are the liver, eyes, brain, and kidneys. The patient displays a resting tremor signifying brain involvement, and the pathognomonic Kayser-Fleischer rings (brownish-green rings on the outer periphery of the cornea) for Wilson disease would be an important physical exam finding.

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This patient has a pericardial effusion as a result of her pericardial inflammation. This is an expected finding and should not change the current medical regimen. Large and/or hemodynamically significant pericardial effusions are rare, but overall a pericardial effusion is present in over half of cases. Cardiac tamponade is very rare.Recall that cardiac tamponade is a clinical diagnosis that is supported by the echocardiogram. Moreover, the size of the effusion does not equal tamponade as small effusions can cause hemodynamic collapse when they accumulate quickly. Therefore, it is the rate of pericardial fluid accumulation that often determines the clinical presentation. Because the pericardium can stretch slowly over time a patient with, for example, breast cancer can have a slowly growing pericardial effusion that can be quite large but because it accumulated slowly, the heart has had time to adapt. When given an echocardiogram that reports a pericardial effusion, you must look for clinical signs of low cardiac output (shock, low blood pressure, altered mental status) along with features that suggest the pericardial pressure is compressing the right atrium/ventricle (right ventricular diastolic collapse). Because of the benign clinical course associated pericarditis, along with the low yield of routine diagnostic testing, it is usually not necessary to establish a definite etiology in all patients with acute pericarditis. In developed countries, unless there is an apparent medical or surgical condition (underlying cancer, etc.) known to be associated with pericarditis, most cases of acute pericarditis in immunocompetent patients are due to viral infection or considered idiopathic and require no further workup.Bottom Line: A pericardial effusion is common after pericarditis and unless it is causing hemodynamic compromise, there is no role for routine sampling. Prednisone should be reserved for refractory cases.

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This patient has developed one of the feared complications of ABRS, which is orbital cellulitis. This infection commonly develops in the setting of ABRS due to direct extension of bacteria from the sinus cavity into the orbit. Commonly it can project through the roof of the maxillary sinus. Additionally, there can be extension through the adjacent soft tissues. The diagnosis of this condition is clinical and is confirmed with radiographic imaging. The presence of pain/difficulty with eye movement, double vision, eye swelling, and erythema should be concerning for orbital infection. The initial imaging test of choice would be with a contrasted CT study of the face and orbits. An MRI could also be performed and has similar accuracy, but it generally slower and more expensive to obtain. Additionally, patients with suspected orbital cellulitis should be evaluated by ENT or ophthalmology in the emergency department and started on IV antibiotics with coverage for MRSA (vancomycin generally). If the sinuses are the suspected source, as in this question, ampicillin-sulbactam can be added to vancomycin as long as there is no concern for CNS involvement. If the CNS is involved, ampicillin-sulbactam has poor penetration, and a 3rd generation cephalosporin should be used with the addition of metronidazole for coverage of anaerobic organisms. General guidelines for sepsis and infection should be followed with the physician obtaining the regular laboratories including a complete blood count, metabolic profile, blood cultures, and lactate. None of these were considered correct answers for this question as these are generally required for all patients with sepsis.

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This patient has erythema chronicum migrans that is characteristic for early, localized Lyme disease. The treatment of choice is doxycycline 100mg by mouth twice daily for 10-14 days. Oral doxycycline, amoxicillin, and cefuroxime axetil have equivalent efficacy for the treatment of early Lyme disease, but doxycycline remains the prefered treatment because it is effective in treating some of the potential coinfecting agents and because doxycycline also has the best penetration into the central nervous system. There are some sources that state that pediatric patients below 8 years old should be treated with amoxicillin due to concern for discoloration of the teeth by doxycycline. However, the American Academy of Pediatrics supports the use of doxycycline for children < 8 years of age if it is administered for ≤21 days. Lyme disease is caused by the spirochete Borrelia burgdorferi. It is most common in the Northeast, Midwest and Northwest United States. Lyme disease has been divided into three stages. Early localized (stage 1) consists of erythema migrans (EM) at the site of the tick bite. It appears 7-10 days after the bite and seen in 80% of patients. It starts off as an erythematous flat annular rash that expands over time. The outer border remains red while the center may clear, turn blue or even necrose giving it the classic "targetoid" appearance. It often appears in the axilla, inguinal region, popliteal fossa or the belt line. On histologic examination, there is vascular endothelial cell injury.

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This patient has experienced barotrauma secondary to mechanical ventilation and has progressed to develop a tension pneumothorax. There is some controversy over the proper course of action when a tension pneumothorax is suspected in hospitalized or even trauma patients. Some people advocate for obtaining a single-view x-ray, if possible, because multiple other entities such as a malpositioned chest tube and atelectasis can masquerade as a tension pneumothorax but do not require chest tube placement. However, most people agree that in patients with all the signs and symptoms of a tension pneumothorax (loss of breath sounds on one side, deviation of the trachea away from that side, hypoxia, tachycardia, and hypotension with distended neck veins) immediate needle thoracostomy should be considered, which would be rapidly followed by chest tube placement. In patients without significant hypotension or respiratory compromise who can wait, after the diagnosis, chest tube placement can be considered without needle thoracostomy. A pneumothorax is the accumulation of air in the potential pleural space found between the visceral and parietal pleura of the lung. A tension pneumothorax develops when air is trapped in the pleural cavity under positive pressure and displaces mediastinal structures, resulting in compromised cardiopulmonary functions because of the excessive pressure. The air under positive pressure in the pleural space collapses the ipsilateral lung and shifts the mediastinum away from the side of the pneumothorax. Unrecognized barotrauma in a mechanically ventilated patient can progress to a tension pneumothorax. Known risk factors include acute lung injury (ALI) and acute respiratory distress syndrome (ARDS). A physical exam may be subtle and includes patient-ventilator discoordination, diaphoresis, tachycardia, and cyanosis if hypoxemia is present. Other clinical features include hypotension as compression on the great veins hinders cardiac filling, neck veins are distended, trachea shifts away from the side of pneumothorax on chest radiograph, decreased breath sounds on the affected side, and hyperresonance to percussion on the side of the pneumothorax. A tension pneumothorax must be treated as a medical emergency, because the patient can die from inadequate cardiac output or hypoxemia.

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This patient has hypercalcemia. The history of abdominal pain, kidney stones, and depression are consistent with this. The most common cause of hypercalcemia in a young, otherwise healthy patient is hyperparathyroidism, usually from a parathyroid adenoma. Thus, measuring parathyroid hormone is the most appropriate next step.

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This patient has notable cognitive impairment as demonstrated by the Montreal Cognitive Assessment and therefore meets the initial criteria for dementia. However, he also has significant symptoms concerning for depression, including anhedonia, withdrawal from interpersonal relationships, a flat affect, and a significant life stressor in the death of his wife. Dementia generally presents with a slow, noticeable decline in cognitive functioning, which this patient does not have. According to the son, he was otherwise normal one year ago, before the death of his wife, and now shows signs of significant depression, which makes pseudodementia the most likely cause of this patient's sudden cognitive decline. Pseudodementia is a serious problem in the elderly, and an incorrect diagnosis can result in the incorrect treatment of dementia and delay treatment of underlying depression. The treatment for pseudodementia is the general treatment for depression, which includes either CBT or drug therapy or both. Drug therapy is generally performed with SSRIs due to their preferable side-effect profile and minimal anticholinergic side effects.

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This patient has pheochromocytoma given the symptoms and the workup he has had so far. Now there is an abdominal CT showing an adrenal mass. This patient will need surgical resection of the mass, but pretreatment is very important in this situation. You have to treat the patient with an alpha-blocker first for 10 to 14 days preoperatively, and then a beta-blocker second 2 to 3 days preoperatively. If you give a beta-blocker first, you will cause worsening hypertension secondary to unopposed alpha-adrenergic stimulation.

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Wilson disease is an autosomal recessive disease affecting chromosome 13. Copper is improperly excreted by the liver, leading to abnormally large deposits of copper in the liver, brain, eyes, kidneys, and other tissues. The disease is generally diagnosed between the ages of 5 and 40 years old, with hepatic symptoms occurring earlier in the disease process and neurologic symptoms occurring later. The most common signs and symptoms are due to the copper deposits in tissues leading to:1) Cirrhosis (jaundice, caput medusa, hepatomegaly, and asterixis)2) Basal ganglia deterioration (tremor, choreiform movements, gait disturbance, dysphagia, behavior disturbances, and psychosis)3) Copper deposits in Descemet membrane of the cornea (Kayser-Fleischer rings)

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This patient has symptoms consistent with carpal tunnel syndrome, which is a distal median neuropathy caused by compression of the median nerve within the carpal tunnel. Individuals who perform repetitive activities at the hand and wrist are at risk for mechanical compression of the median nerve at the carpal tunnel. Classic symptoms are paresthesias in the thumb, index finger, and middle finger that are worse at night. In severe or chronic cases, there can be atrophy of the thenar eminence. Although nerve conduction studies are the gold standard for diagnosis, a good history and physical exam can confirm the diagnosis. During a Phalen's test, a patient is instructed to push the dorsal surfaces of each hand together, which decreases space in the carpal tunnel; this position is held for 60 seconds with a reproduction of symptoms resulting in a positive test. The rest of the answer choices are all used in the diagnosis of carpal tunnel syndrome and should be familiarized.

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This patient is demonstrating classic findings of dermatomyositis, which is a type of idiopathic inflammatory myopathy affecting multiple organ systems. Most patients present with eczematous skin findings, which cause severe itching. Involvement of the musculature is also common and manifests as proximal muscle weakness noted while attempting to climb stairs, reaching for items overhead, or arising from a seated/supine to standing position as in the above case. Classic skin manifestations include a periorbital rash that is described as "heliotrope" and purple in color, as well as scaling plaques over the PIP and DIP joints, known as "Gottron papules." Shawl sign is also seen in this disorder and is a rash that appears over the shoulders, upper chest, and back. The x-ray of this patient shows diffuse soft-tissue calcifications, which can also be seen in this disorder.

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This patient is demonstrating symptoms consistent with postnatal acquired rubella. Classic rubella is characterized by onset of low-grade fever, rash, and lymphadenopathy. Suboccipital and postauricular nodes are commonly (and classically on COMLEX) involved. A faint maculopapular rash is typically seen on the face following a two or three day prodrome. The rash spreads from the face to the toes similarly to what is seen in cases of measles. Treatment is supportive.

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This patient is hemodynamically stable with likely bleeding esophageal varices. Therapeutic endoscopy with variceal ligation and banding is the treatment of choice to stop the acute blood loss in stable patients. The initiation of octreotide would be performed as soon as a variceal bleed was suspected. This is a somatostatin analogue that can decrease splanchnic blood flow and reduce clinical bleeding. Additionally, any patient with cirrhosis and upper gastrointestinal bleeding should be started on prophylactic antibiotics for a 7-day course because these patients are more likely to develop spontaneous bacterial peritonitis and bacteremia due to compromised mucosal barriers. The most commonly used antibiotics for this indication include intravenous ceftriaxone with conversion to oral trimethoprim-sulfamethoxazole or oral ciprofloxacin. If this patient had persistently unstable vitals with continued severe hemorrhage, balloon tamponade could be considered because esophagogastroduodenoscopy (EGD) is difficult in the setting of diffuse bleeding.

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This patient is presenting back to your office with a complaint of double-sickening or sudden worsening of rhinosinusitis, which was previously improving. Additionally, he now has a fever which was not present previously. Given this, he now meets criteria for presumptive acute bacterial rhinosinusitis (ABRS). ABRS, like its viral counterparts, will normally improve without antibiotic therapy. The guidelines from the American Academy of Otolaryngology still recommend 7 days of watchful waiting in the setting of uncomplicated ARBS unless the patient is immune compromised or has persistent fevers. If signs of complicated infection are present, the patient will need immediate antibiotic administration and general admission to a hospital to allow rapid workup and evaluation. The treatment for uncomplicated ARBS includes supportive care and watchful waiting if the patient has good follow-up. If the patient does not have a good follow-up, as in this case (he will be out of the country), antibiotics should be prescribed. The antibiotic of choice in the setting of uncomplicated ARBS is amoxicillin, with or without clavulanate. The use of other antibiotics is currently discouraged. If the patient is penicillin allergic, then doxycycline can be used. In children, who cannot take doxycycline, a respiratory quinolone could be used instead.When to use amoxicillin with clavulanate is beyond the scope of this question and probably what should be known for Step 3, however, generally clavulanate would be used if there is a risk for immune compromise, recent antibiotic use, severe symptoms, or significant other medical comorbidities. Though MRSA can populate the nasal passages, it is a rare cause of ABRS, and Staph coverage or MRSA coverage is not routinely recommended at this time.Bottom Line: In patients with ABRS who require antibiotic therapy, the initial therapy of choice is with amoxicillin with or without clavulanate.

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This patient is presenting to you for medical clearance as requested by his orthopedic surgeon. In addition to a complete history and physical exam, certain objective studies can be used to evaluate the health of a patient to determine if they are healthy enough to undergo an elective operation: A 12-lead ECG is considered reasonable for patients with known cardiovascular disease or arrhythmia (except for those undergoing low-risk surgery). Chest x-ray can be considered for patients at risk of pulmonary complications postoperatively but is not routinely performed in asymptomatic patients. Pharmacologic stress testing is recommended for higher risk patients with unknown or poor functional capacity, defined as being able to perform less than 4 METs (metabolic equivalent task). Generally, walking up a flight of stairs without pain or shortness of breath requires more than 4 METs. Coronary angiography would be recommended if the patient has an abnormal pharmacologic (or exercise) stress test Although this patient is in the higher risk category with known coronary artery disease, diabetes, and significant smoking history, he states he regularly goes up 3 flights of stairs, indicating he has good functional capacity. Because of this, no further testing is necessary.

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This patient is presenting with a case of giardiasis. Giardia lamblia is an anaerobic flagellated protozoan parasite that is the most common parasitic infection in the world and the most common waterborne illness in the United States. Symptoms may include nonbloody diarrhea, steatorrhea, abdominal pain, or weight loss. Diagnosis can be confirmed by obtaining stool ova and parasite, which reveals the presence of cysts and trophozoites (pear-shaped) or stool antigen testing. Risk factors include environments of poor sanitation or close contacts with others infected (e.g. day care centers), sexually transmitted infection (e.g. oral sex, anal sex), ingestion of contaminated water in the wilderness, or exposure to infected animals (e.g. beavers, cattle, dogs, rodents). Primary treatment options include nitazoxanide, tinidazole, or metronidazole.

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This patient is presenting with acute, complicated diverticulitis with abscess. In general, most abscesses should be at least considered for drainage if possible with few exceptions (lungs being one site which can be treated with antibiotics). In this case, interventional radiology (IR) would allow the patient the greatest benefit with the least invasive procedure; however, if the patient does not improve and the abscess cannot be drained, surgery will be required. Any patient presenting with complicated diverticulitis will require admission and those with sepsis should receive fluids at the recommended bolus amount of 30 mL/kg and broad-spectrum antibiotics. Given the patient's peritoneal signs with sepsis, he should also be evaluated by surgery. This patient most likely needs an invasive procedure and should be kept NPO.To get credit for this question you needed to have realized that the patient was presenting with sepsis and should be given antibiotics and fluids and that diverticular abscesses need drainage. The least invasive method is with interventional radiology.This patient has a slightly decreased blood pressure and tachycardia but does not appear to be in shock. He does not need an ICU consultation or intubation at this time. If he failed to respond to fluids and antibiotics and continued to decline then critical care evaluation would be warranted. Many patients improve substantially with fluids.An NGT may be helpful if the patient has abdominal distension with persistent nausea and vomiting but is not mandatory.This patient has an abscess which needs to be drained as well as signs of peritonitis with guarding and rebound on exam. If IR is able to drain the abscess percutaneously, it can spare the patient a trip to the operating room. However, if it is not in an easily accessible area (for example, obscured by bowel or deep in the pelvis), then the abscess may need to be drained surgically.

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This patient is presenting with concern for postoperative complications; however, it should also be considered that this may be a new problem not related to her surgery. General laboratory workup as previously described in the last question is still required for the same reasons. This includes complete blood count (CBC) to evaluate WBC count, basic metabolic panel (BMP) for renal function and electrolytes, as well as consideration of a hepatic panel for liver function. A urinalysis is helpful in the workup of abdominal pain in a female and should be sent with a urine pregnancy test. Just because this patient had surgery recently does not mean she does not have an unrelated problem such as nephrolithiasis or a urinary tract infection. If she is not pregnant, she should be reimaged with another CT to look for residual fluid collections, abscesses, or signs of postsurgical pathology. Again, other imaging would be redundant and will not reveal an abscess, if present, or will take longer than necessary (such as an MRI).International normalized ratio (INR) is not necessary because the patient is not on blood thinners and does not have a history of coagulopathy. However, if some kind of pathology was found on CT scan, then an INR might be necessary before intervention. It would not be unreasonable to obtain an INR during the initial evaluation, depending on the physician's level of concern and the surgeon's comfort.A lactic acid evaluation is not strictly necessary in this case as the patient is not presenting with sepsis; however, it could be obtained if there was concern for bowel necrosis.A surgical consultation is required at some facilities in postsurgical patients but would not be required urgently or before the results of the CT scan have returned.

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This patient is presenting with signs and symptoms of mild to moderate pelvic inflammation disease (PID) and combination therapy with ceftriaxone and doxycycline should be initiated empirically for Neisseria gonorrhoeae and Chlamydia trachomatis, respectively. In severe disease or patients who require hospitalization consideration can be made for the addition of metronidazole to cover anaerobic organisms, however, this is not routinely recommended for outpatients. Treatment protocol (generally this treatment is not stopped or cut short if cultures are negative): Doxycycline (100mg twice daily for 14 days) or azithromycin (1 gram once weekly) Choose a long-acting cephalosporin (single dose)ceftriaxonecefoxitincefotaximeceftizoxime If there has been gynecologic instrumentation within the past few weeks or documented T. vaginalis infection or bacterial vaginosis add:metronidazole (500mg twice daily for 14 days)

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This patient is presenting with signs and symptoms of ocular myasthenia gravis (MG). MG is an autoimmune disorder in which the antibodies attack the acetylcholine receptor proteins at the neuromuscular junction. This causes weakness and fatigability of the skeletal muscles involved.Historically, diagnosis could be supported by nonspecific testing such as the ice pack test and the edrophonium (Tensilon) test. However, because serologic testing and electrophysiologic testing have improved sensitivity and specificity and are often readily available, they have supplanted classic examinations in establishing diagnosis of MG. Antibodies classically associated with MG include autoantibodies against the acetylcholine receptor (AChR-Ab) and muscle-specific tyrosine kinase (MuSK-Ab). Their sensitivity correlates with severity of disease, with up to 93% of patients with generalized disease having AChR-Abs and only 50% to 71% of patients with ocular disease having AChR-Abs. Among patients with negative AChR-Ab, MuSK-Abs are positive in up to 50% of patients with generalized disease. However, anti-MuSK-Abs are often negative in patients with purely ocular symptoms. A generalization of sensitivity of testing on affected individuals and healthy controls is summarized in the table below.

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This patient likely has cellulitis and infection due to Staphylococcus aureus due to the purulent nature of his infection given his cellulitis with an associated fluid pocket. This is likely an adjacent abscess. He is also at high risk for S. aureus infection due to his IV drug abuse. Staphylococcus aureus and Group A Strep (pyogenes) are the two common organisms that cause localized skin infections such as cellulitis. These pathogens generally enter through a break in the skin. Group A strep can form flat, non-purulent cellulitis, impetigo, or erysipelas. As opposed to streptococcal cellulitis, staphylococcal cellulitis typically presents with a more purulent cellulitis or with an associated abscess. Staph aureus can be both methicillin-sensitive or resistant. Once thought to be a predominantly health-care-associated infection, Methicillin-resistant Staph aureus (MRSA) has become a prominent cause of cellulitis in community-dwelling adults in the United States. In this particular patient, the organism is likely Staph aureus as the cellulitis appears with an associated abscess. If there is a high community prevalence of MRSA, then the patient will need to be treated as such until cultures have returned. Treatments for MRSA vary from MSSA (methicillin-susceptible Staph aureus) and Strep. species. Oral antibiotics that cover MRSA include clindamycin, bactrim, and doxycycline. MRSA that requires an inpatient stay can be treated with IV Vancomycin or daptomycin. Linezolid is another oral option, but it is rarely used due to high cost and potential for bone marrow suppression. Oral treatments for both MSSA and strep include cephalexin or clindamycin. IV treatment would include cefazolin.

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This patient is presenting with symptoms and lab findings consistent with pyelonephritis, however, a computed tomography scan reveals air in the renal parenchyma, indicating the patient has emphysematous pyelonephritis. Emphysematous pyelonephritis is caused by an infection of the renal parenchyma and sometimes perirenal tissue that is gas-producing and necrotizing. Among the bacteria associated with EPN, Escherichia coli is isolated in 66% of patients and Klebsiella species are reported in 26%. Proteus, Pseudomonas, and Streptococcus species are other organisms found in patients with EPN. Mixed organisms are observed in 10%. Positive blood culture results are identical to urine culture results in 54% of patients. Rare organisms such as Clostridium and Candida species have also been isolated in patients with EPN. Recently, Entamoeba histolytica and Aspergillus fumigatus have been reported as causes of EPN. Transplanted kidneys may be susceptible to EPN because of associated high-risk factors in the recipient such as diabetes and immunosuppression.Patients typically present with symptoms including fever, abdominal or flank pain, nausea, and vomiting, dyspnea, acute renal impairment, altered sensorium, and/or shock. Laboratory findings include leukocytosis with a left shift, pyuria, thrombocytopenia, elevated creatinine, and positive blood cultures. Computed tomography (CT) scanning is the definitive imaging test and reveals gas patterns that are streaky, streaky and mottled, or streaky and bubbly, in addition to gas collections in the perinephric area.Diabetes mellitus and urinary tract obstruction are major risk factors. Diabetes is present in more than 80% of patients with emphysematous pyelonephritis and one study indicated up to 96% may be diabetic. Management of emphysematous pyelonephritis includes prompt hydration with fluid resuscitation and treatment with systemic antibiotics.

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This patient is presenting with symptoms of acute on chronic congestive heart failure (CHF). In addition to using medications the patient's leg swelling can be safely treated with osteopathic lymphatic treatments. Keep in mind, the risk-to-benefit ratio for lymphatic techniques is quite good. No known significant complications have resulted from osteopathic lymphatic treatment to date, and multiple published studies have documented the efficacy of various lymphatic treatments.Nonetheless, clinical judgment should always be used when prescribing treatment for a patient in any disease state.The lymphatic treatments can be divided into 2 categories: those that improve restrictions and those that augment lymphatic flow. Treatment protocols should include techniques from both categories.First, start with techniques that improve restriction, and then apply techniques that augment flow. A basic sequence for a lymphatic treatment program should include: Treat any thoracic inlet somatic dysfunction Rib raising or paraspinal inhibition to improve respiration and normalize hypersympathetic activity Redome the thoracoabdominal diaphragm to maximize lymph return Apply lymphatic pump techniques to return lymph through open channels Note that the lymphatic pump is the final step as it is most effective when the restrictions have already been treated Prior to treatment, recall the following relative contraindications to lymphatic treatments: Osseous fractures Bacterial infections with a temperature >38.9°C (>102°F) Abscess or localized infection Certain stages of carcinoma

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This patient is suffering from early Lyme disease. Although doxycycline is the desired therapy for early-stage Lyme disease due to its coverage of anaplasma phagocytophila (the agent responsible for causing Human Granulocytic Ehrlichiosis), which is difficult to distinguish from the presentation of Lyme disease, this drug would not be desired in the above patient due to her pregnancy. In pregnant and/or lactating women, amoxicillin would be the preferred drug of choice. Amoxicillin would also be the drug of choice to use in children because of the lack of side effects, such as skeletal and dental problems, that are seen with the use of doxycycline. No life-threatening effects on the fetus have been found in cases where the mother receives appropriate antibiotic treatment for her Lyme disease. In general, treatment for pregnant women is similar to that of non-pregnant adults, although certain antibiotics, such as doxycycline, are not used because they can affect fetal development. A typical treatment would include oral amoxicillin 500 mg three times daily for 2-3 weeks. Women who are allergic to amoxicillin would most likely receive 500 mg cefuroxime axetil twice per day.

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This patient is suffering from hyperglycemic hyperosmolar syndrome (HHS). Classically, HHS is seen in type 2 diabetics who still produce enough insulin to prevent ketosis. Patients will present with profound dehydration secondary to the osmotic effects of glucose. Symptoms may be mild or severe, ranging from polyuria and polydipsia, to coma and death. The diagnosis is made based on history, exam and laboratory findings of hyperglycemia (with glucose often >600 mg/dL), and increased serum osmolarity (Often > 350 mOsm/L) / increased serum osmolality (often >320 mosmol/kg; (Reference range: 275 to 295 mosmol/kg)). Ketones may be absent or low. On initial presentation, DKA must be considered in the differential, but should later be ruled out by the absence of acidosis on blood gas and a normal HCO3-. HHS can be caused by infection, stress, dehydration, or non-compliance with medication.

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This patient is suffering from panic disorder, which is an anxiety disorder causing recurrent panic attacks in addition to fear of when the next attack may occur and behavioral changes lasting at least 1 month. Per the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V), a panic attack is the sudden onset of 4 or more of the following symptoms: palpitations or increased heart rate, sweating, trembling, shortness of breath, chest pain, nausea, feeling dizzy or faint, depersonalization, fear of losing control, fear of dying, paresthesias, and chills or hot flashes. Benzodiazepines have been shown to reduce panic severity but are no longer first line. The antidepressants, generally selective serotonin reuptake inhibitors (SSRIs) due to favorable side effect profile, are now first line in the treatment of anxiety, depression, and panic disorder. They will take up to 6 weeks to reach full effect. Panic disorder is separate from generalized anxiety disorder, which is at least 6 months of excessive worry that inhibits a person's daily functioning. Management of panic disorder involves the use of cognitive-behavioral therapy in addition to an SSRI.

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Tuberous sclerosis is an autosomal dominant disorder that is caused by mutations in hamartin and tuberin. Patients present with seizures secondary to cortical tuber, intellectual disability, ash leaf spots (hypomelanotic patches), shagreen patch, and adenoma sebaceum (facial angiofibroma). It is also associated with epilepsy, intellectual disability, and autism.

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Type I hypersensitivity reactions are IgE-mediated reactions that are immediate and may cause anaphylaxis. Examples include allergic rhinitis from pollens and allergic reactions to foods such as peanuts and shellfish.

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This patient may have an ectopic pregnancy. Since the pregnancy is desired, the next step is to figure out whether the pregnancy is a viable intrauterine pregnancy (IUP), a nonviable IUP or an ectopic pregnancy; this requires close clinical follow up with serial hCG measurements and often repeat ultrasound exams. It is important to remember that in early pregnancy, absence of IUP on imaging does not completely exclude presence of IUP. If bHCG is to be used as a diagnostic tool in women at risk of ectopic pregnancy the discriminatory level at which an IUP can be seen on ultrasound should be conservatively high (up to 3500 mIU/mL). Prior to treating an ectopic pregnancy, serial bHCG measurements done at 48 hour intervals should reveal that the pregnancy is nonviable via a falling bHCG or one that rises less than 50%; additionally, ectopic pregnancy can be diagnosed by visualization of a mass with yolk sac outside of the uterine cavity. Premature treatment for ectopic pregnancy, including surgery or medical treatment with methotrexate, could damage a desired IUP.

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This patient most likely had a transient ischemic attack (TIA). It is classified as a history of transient neurologic deficit without signs of ischemia or structural damage on a neuroimaging modality such as a magnetic resonance imaging. Regardless of duration, whether less than 24 hours, if evidence of ischemia is seen on neuroimaging (with or without resolution of symptoms), a diagnosis of stroke is made, not TIA. TIAs can be caused by atherosclerosis of extracranial vessels, such as the internal or common carotid, basilar, and vertebral arteries, or emboli from the aorta or heart. Atrial fibrillation is a common arrhythmia associated with the formation of atrial thrombi, which are susceptible to embolization to the brain. Treatment is directed at any underlying cause and modification of risk factors.

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This patient presents with a laboratory workup consistent with syndrome of inappropriate antidiuretic hormone (SIADH). The general workup of hyponatremia includes evaluation of volume status: hypo-, hyper-, or euvolemic. In this stem, there is nothing to indicate hypervolemia, and all of the data point against hypovolemia (negative orthostatics, not hypotensive, not tachycardic), and therefore the patient is most likely euvolemic. In addition to volume status, certain studies can be obtained including a serum osmolality (should be <280 if it is a true hyponatremia and not pseudo-), urine sodium, and urine osmolality. No other studies need to be obtained initially unless there is a strong suspicion for a secondary problem. Given that this patient has a high urine sodium and high urine osmolality (>400 mOsm/kg) despite hyponatremia and is likely euvolemic, the most likely underlying cause is SIADH. Given that her mental status is at baseline despite significant hyponatremia, this is likely a chronic process.There are many different causes of SIADH. They include the following: Head injury Central nervous system surgery Certain medications including morphine, nonsteroidal anti-inflammatory drugs, and oxytocin Hypothyroidism Glucocorticoid deficiency Small cell lung cancer Pancreatic malignancy Thymoma Hodgkin disease Patients with SIADH are usually euvolemic. They have increased urine osmolarity due to secretion of antidiuretic hormone (ADH), which causes a concentrated urine. They generally have an increased urine sodium secondary to increased total plasma volume, which can result in renal sodium excretion in an attempt to normalize plasma volume. This is generally marginally successful, which is why patients with SIADH do not generally appear volume overloaded but remain relatively sodium deficient. The treatment of this condition is based on treating the underlying cause, if possible, and water restriction to prevent further retention of free water. The discussion of treatment of hyponatremia is complicated and beyond the arc of this question.

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This patient presents with hyperkalemia and has evidence of ECG changes (peaked T waves in leads V2-V6). This represents a medical emergency and requires prompt intervention. The initial step in management is administration of calcium gluconate to stabilize cardiac membranes and prevent further arrhythmias. Ideally, the patient will be linked up to either a running ECG strip or a cardiac monitor, and calcium should be repeated until the ECG changes resolve. The patient then needs medications to lower the potassium level by shifting it intracellularly. Options for reducing blood potassium include insulin plus glucose (usually D50), high-dose albuterol, and if the patient is acidotic, bicarbonate. Definitive management can be pursued after these life-saving interventions. Often the serum potassium can be successfully reduced with medical management alone. If medical managment fails, then the patient will need hemodialysis.

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This patient should be classified as having mild cognitive impairment. While seemingly extreme, this case was produced from an actual clinical example in which a patient with mild cognitive impairment and severe depression was misclassified as having Alzheimer's dementia until the depression was adequately treated and the cognitive impairment was uncovered. In the case above and in the actual case, the patient's wife managed to prevent the diagnosis of cognitive impairment (due to unconscious compensation for her husband's impairment) until her death. The diagnosis of mild cognitive impairment should be made when a patient presents with impaired cognition (usually in memory) but is able to compensate and still perform their activities of daily living. This patient can now perform all of his ADLs without assistance and can perform his IADLs with compensation. To be classified as dementia, he must have deficits in performing his ADLs or IADLs.

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This patient shows signs of cirrhosis secondary to alcohol abuse. However, the most common cause of cirrhosis in the United States is hepatitis C virus (HCV) infection. HCV infection is usually diagnosed with a screening antibody test and confirmed with HCV RNA testing. It is most commonly transmitted through parenteral exposure in the form of intravenous drug use. Blood transfusion was previously a major risk factor for HCV infection, and a number of individuals have chronic infection from past transfusions. However, with newer testing, the risk has become very low (1 in a million transfusions). Cirrhosis results in multiple complications and physical exam findings. Portal hypertension can result in varices in the esophagus, umbilicus, and rectum. Gynecomastia and spider angiomata are due to increased estrogen levels. Asterixis (liver flap) suggests hepatic encephalopathy.

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This patient's presentation with tachycardia, hypertension, combativeness, formication, and acute myocardial infarction, is concerning for cocaine overdose.Cocaine intoxication causes sympathetic stimulation (insomnia, tachycardia, mydriasis, hypertension, sweating) with hyperalertness and aggression, delirium, psychosis, or formication (the feeling of bugs crawling on or under a person's skin) - this is also known as a "tactile hallucination." Cocaine affects the cardiovascular system from alpha- and beta-1-receptor stimulation resulting in increased heart rate, systemic arterial pressure, and myocardial contractility. Cocaine may also cause arterial vasoconstriction hours after use. The coronary arteries are especially vulnerable to these effects, leading to decreased myocardial oxygen supply. This causes chest pain and subsequently myocardial infarction. Cocaine also induces platelet activation and plasminogen activator inhibitor which promote thrombosis.

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Type II hypersensitivity reactions are cell surface antigen-antibody cytotoxic reactions. Antibodies (IgG and IgM) are directed against an intrinsic or extrinsic antigen, forming an antigen-antibody complex and activating the classical complement pathway. Transfusion reactions, autoimmune hemolytic anemia, and Goodpasture syndrome are examples of type II hypersensitivity reactions.

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This patient's symptoms are most consistent with Meniere's disease which is caused by an increased volume of endolymphatic fluid in the inner ear. Most common between 30 and 60 years of age, Meniere's disease presents episodically with attacks lasting from several minutes to hours. Characterized by a constellation of symptoms including ear fullness, vertigo, tinnitus, and hearing loss, diagnosis can often be made clinically. The American Academy of Otolaryngology Head and Neck Surgery diagnosis of Meniere's disease breaks it down based on certainty. To be classified as "definite", there needs to be two or more episodes of rotational vertigo lasting more than 20 minutes PLUS audiometrically confirmed sensorineural hearing loss, tinnitus, aural fullness, in addition to other causes excluded. On audiometric evaluation, patients will commonly exhibit a low-frequency or combined low-high frequency sensorineural hearing impairment. Treatment includes caffeine and salt restriction, vestibular rehabilitation, intratympanic steroids and gentamicin. There are very few randomized-controlled trials to guide therapy. Osteopathic Pearl: There are six types of strains that can occur at the sphenobasilar synchondrosis (SBS): flexion/extension, torsion, sidebending/rotation, vertical strain, lateral strain, and compression. The osteopathic findings stated above describe an extension dysfunction. Flexion and extension are natural physiologic components of cranial movement. However, a strain pattern occurs when the mechanism does not move through flexion and extension equally. An extension dysfunction occurs when the SBS deviates caudad, decreasing the amount of flexion at the SBS. Conversely, a flexion dysfunction occurs when the SBS deviates cephalad, decreasing the amount of extension at the SBS.

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This woman is most likely pregnant since her B-hCG is elevated. Whether or not her pregnancy is intrauterine or ectopic cannot be determined at this time. This is because her hCG has not reached the threshold for detecting an intrauterine gestational sac by ultrasound. The threshold for a transvaginal ultrasound is about 1500mIU/mL. A rise of hCG of at least 65% after 48-hours is a good indication that the pregnancy is normal. A plateau in hCG over 48-hours indicates a non-viable pregnancy.

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This woman is presenting with preterm premature rupture of membranes (PPROM) complicated by an intrauterine infection, suggestive of chorioamnionitis. Maternal fever and fetal tachycardia (fetal heart rate > 160 beats/min) are physical signs consistent with chorioamnionitis. There is an increased risk of infection 18-hours after rupturing membranes. PPROM is diagnosed when the membranes of pregnancy rupture greater than 18 hours before labor. Some risk factors for developing PPROM include infection, smoking and anatomic defects of the uterus or cervix. It can be diagnosed by using nitrazine testing or looking for ferning patterns on microscope slides.

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Thoracic curves >50° will usually result in respiratory compromise. Cardiac compromise may occur with curves between 50-75° but most often will happen with curves >75°.

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Thoracic inlet release also improves lymphatic congestion; it is contraindicated in patients with upper rib or clavicle fracture. It is an appropriate treatment for patients who have recently undergone abdominal surgery.

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Thoracic outlet syndrome is a group of disorders resulting from compression of the vascular or peripheral nervous syndrome at the level of the first rib and clavicle. The condition results in numbness, parasthesias, and pain in the distribution of the shoulder, elbow, and hand. Thoracic outlet release is an OMT technique directed toward easing muscular restrictions and decreasing symptoms.

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Thrombocytopenia after eating a hamburger is the classic presentation for hemolytic uremic syndrome (HUS). In this syndrome anemia and signs of acute renal failure are expected.

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Torsion occurs when the sphenoid rotates about an anterior-posterior axis relative to the occiput at the SBS.

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Transient synovitis patients are typically younger, between 4 and 8 years old, and have a history of an upper respiratory infection. Treatment of choice is nonsteroidal anti-inflammatory drugs.

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Trauma, most commonly caused by "nose-picking," is the most common cause of epistaxis in the pediatric population. Epistaxis or nosebleed refers to blood flowing from the nose or nasal passage. Nosebleed symptoms differ, depending on where in the nose the bleeding begins. Anterior nosebleeds often produces blood flow from one nostril when the patient sits or stands. Blood may pass down the throat if the person is coughing or blowing the nose. Posterior nosebleeds cause bleeding down the back of the mouth and throat. When the patient leans forward, the blood may flow from the nostril. Blood flow may be fast or slow. Most anterior nosebleeds stop without medical care within 15 minutes. Posterior nosebleeds usually are more serious and need medical care. Treatment with prolonged and sustained direct pressure and topical nasal vasoconstrictors is the primary treatment. Cauterization with silver nitrate or nasal packing is reserved for refractory bleeding.

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Treatment of generalized psoriasis not responsive to topical corticosteroids involves the use of ultraviolet (UV) light, such as UVB or psoralen and UVA (PUVA), and/or biologic therapies. A dermatology referral would also be an appropriate step in this patient's management.Do not treat psoriasis with systemic corticosteroids. This is a chronic condition, and the long-term benefits associated with the use of steroids in patients with psoriasis do not outweigh the risks. Disease is likely to recur after discontinuation of therapy.

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Tricyclic antidepressant toxicity does cause inhibition of potassium channels, which leads to QTc prolongation and may lead to torsades de pointes.

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Tuberous sclerosis complex (TSC) needs to be considered in the differential diagnoses of patients presenting with multiple renal lesions. Renal cysts occur in both TSC and VHL disease; however, renal tumors typically seen in TSC are angiomyolipomas, which have a characteristic appearance on abdominal CT scanning and MRI. Unlike VHL disease, TSC is a neurocutaneous disorder characterized by neurologic and dermatologic findings (this patient has no dermatologic findings). Salient dermatologic findings of TSC are hypopigmented macules (ash-leaf spots), shagreen patches, periungual fibromas, and adenoma sebaceum. Seizure disorders and learning disabilities are also part of the TSC clinical spectrum.

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Type III hypersensitivity occurs when antigen-antibody complexes that are not adequately cleared by innate immune cells accumulate, giving rise to an inflammatory response and attraction of leukocytes.

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Upon further history you would find that this patient had been drinking 1 pint of cognac daily for years and decided to drive from Chicago to San Antonio for a job opportunity without having a drink for 24 hours. The longer a patient has been abusing alcohol the more severe the withdrawal. Minor symptoms usually occur within 6 hours of last drink and include insomnia, tremors, anxiety, gastrointestinal upset, anorexia, headache, diaphoresis and palpitations. Mild symptoms usually resolve in 24-48 hrs. Withdrawal seizures are typically tonic-clonic and occur within 48 hrs of last drink; treat these with benzodiazepines or phenobarbital. Alcoholic hallucinosis occurs within 2-7 days, patients typically have visual hallucinations without clouding of the sensorium. Delirium tremens (DT) are characterized by hallucinations, disorientation, tachycardia, hypertension, fever, agitation, and diaphoresis. DT's can last up to seven days. Patients have highly increased cardiac indices, oxygen delivery and oxygen consumption. Arterial pH increases due to hyperventilation which causes decreased cerebral blood flow. You can also see low potassium, magnesium and phosphate. Management of DT's is with symptom triggered benzodiazepine therapy CIWA scale (Clinical Institute Withdrawal Assessment for Alcohol scale). Also give fluids, thiamine before glucose, folate and correct electrolyte abnormalities.

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Urinary tract infections (UTIs) place women at an increased risk of developing spontaneous abortion, specifically in the second trimester. Other sequelae associated with untreated UTIs include low birth weights, hypertension, and/or preeclampsia, maternal anemia, and amnionitis. In addition, in most women the uterus leans slightly to the right. As the fetus grows, enlarging the uterus, it is possible for the right ureter to become compressed. If this happens and the mother has a UTI or untreated asymptomatic bacteriuria, she is at high risk for pyelonephritis and sepsis. For these reasons, UTIs and asymptomatic bacteriuria in pregnant women must be treated.

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Vancomycin covers gram positive organisms, but not gram negatives, and most of her UTIs have been E. coli. If a patient has risk factors of Enterococcus, such as prolonged urinary catheter or previous Enterococcus UTIs, then vancomycin could be considered. This patient has none of those risk factors so this medication is inappropriate.

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Varicella (aka chickenpox) has a characteristic rash that appears in different progressive stages (from discrete macules to papules to vesicles to crusted lesions). These lesions appear in clusters at different stages of development.

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Varicella is known by its generalized, pruritic, teardrop vesicular rash that begins on the trunk and spreads to the extremities, and lesions often present at different stages of healing.

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Vascular dementia is the third most common cause of dementia after Alzheimer's and Lewy-body dementia. It is generally caused by ischemic damage and is often progressive in a step-wise fashion. Meaning, there are generally recognizable insults (small strokes) which result in decreased functioning, which does not return to baseline. The cognitive deficits seen in vascular dementia will correspond to the areas of cerebral infarction.

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Venous stasis ulcers are associated with increased pigmentation and an inflammatory reaction caused by a valve defect in the superficial veins of the lower limb. They are most common on the medial surface of the lower legs.

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Vitamin B12 deficiency presents as a macrocytic anemia, often with neurological symptoms. (Folic acid deficiency is also macrocyctic, however, there are no associated neurological symptoms.) This patient is a vegan, and therefore over time likely has developed vitamin B12 deficiency due to lack of consumption of red meats that are high in B12. Increased methylmalonic acid and homocysteine levels is diagnostic of vitamin B12 deficiency (cobalamin deficiency). B12 deficiency is also seen in Crohn disease, terminal ileum resection, chronic pancreatitis, and Diphyllobothrium latum consumption.The peripheral smear reveals macrocytes and hypersegmented neutrophils. With time, the patient will present with neurological symptoms including ataxia, spasticity, and parasthesias. The Schilling test can be used for the purpose of diagnosis to determine if the B12 deficiency is caused by pernicious anemia. The Schilling test involves administration of oral radiolabeled vitamin B12 followed by injected vitamin B12 that is unlabeled. The unlabeled B12 then saturates the receptors in the liver and body tissues, and allows the radiolabeled B12 to be absorbed into the GI tract and pass into the urine. Patients with pernicious anemia have impaired absorption of vitamin B12 and therefore the level of radiolabeled B12 in the urine will be low (<10%).

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Voiding after sexual intercourse has never been proven to affect rates of urethritis in patients with a previous history of urinary tract infection (UTI). However, in one study, it has shown efficacy at preventing the development of UTI in patients without prior history of UTI, although the study was small. Urethritis can be noninfective, and it is still reasonable to recommend that the patient use postcoital voiding to help prevent further episodes of urethritis. This theoretically acts as a "washing method" to expel bacteria from the urethra. The recommendation may help and has no chance of harm, so it is generally still recommended. The other answer options are incorrect for the reasons listed.

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When a discrepancy exists between gestational age and fundal height, you must consider a couple of reasons. First, you must evaluate her gestational age. It is possible that her pregnancy was not dated well, and thus her fundal height is more consistent with an appropriate gestational age. The patient in this scenario has had sufficient prenatal care. Her pregnancy was dated by an early ultrasound that was consistent with her last menstrual period. Second, you should consider the possibility of accelerated fetal growth. This occurs more commonly in pregnancies complicated by gestational diabetes. In this scenario, the exam is more consistent with polyhydramnios. This is the other culprit for discrepancy between fundal height and gestational age. Polyhydramnios is the presence of excess amniotic fluid in the gestational sac. It is diagnosed by ultrasound. During an ultrasonic exam, the uterus is divided into four quadrants, and the maximum vertical pocket in each quadrant is measured. These numbers are summed to get the amniotic fluid index (AFI). An AFI ≥ 25 cm is considered diagnostic of polyhydramnios. The etiologies of polyhydramnios can be normal pregnancy, uncontrolled diabetes mellitus (DM), multiple gestation, pulmonary abnormalities, or fetal anomalies.

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Wilson disease commonly presents with a combination of neurologic symptoms and liver disease. The presence of Kayser-Fleischer rings (green-brown rings surrounding the irises) will help to differentiate it from hepatic encephalopathy.

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Wolff-Parkinson-White (WPW) patients have a short P-R interval because conduction from the atria to the ventricle is not through the normal atrioventricular (AV) pathway, but rather through an accessory pathway also known as the bundle of Kent. The anomalous route bypasses the AV node, which normally slows conduction, and the ventricle is activated earlier. In patients with accessory pathways with very short refractory periods, it is possible for atrial arrhythmias such as atrial fibrillation or atrial flutter to conduct through the accessory pathway and activate the ventricle using 1:1 conduction. For atrial fibrillation, rates in the atria can be as high as 300/min or more, which, at 1:1 conduction, can result in complete loss of cardiac filling and cardiac output. This can result in syncope or sudden cardiac death if the arrhythmia is not terminated.

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Women with a previous pregnancy affected by a neural tube defect (NTD) are at higher risk for having an offspring with a NTD in a subsequent pregnancy. The etiology of NTDs has been associated with an increased folate demand in pregnancy, combined with a decreased dietary intake of folate. It has been shown that supplementation with 1-4 mg/day (4000 mcg/day) of folate, initiated 1 month prior to conception and continued through the first trimester, reduced the risk of repeat NTD in those with a history of carrying a child with a NTD. After the first trimester, the dose should then be reduced to the standard dose of .4 mg/day. This high dose folic acid is only used in those with high risk of having children with a NTD.

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Zollinger-Ellison syndrome is characterized by gastric acid hypersecretion resulting in severe, recurrent acid-related peptic ulcer disease and diarrhea. Zollinger-Ellison syndrome typically occurs secondary to the presence of a gastrinoma (gastrin-secreting tumor) in the duodenum or pancreas. Gastrin is released by the G cells of the stomach antrum. Gastrin stimulates the release of gastric acid from the parietal cells of the stomach, and facilitates proliferation of the gastric epithelial cells. Abnormal gastrin production occurs in some clinical and diseased states, resulting in hypergastrinemia, and is defined by a gastrin level greater than 100-150 pg/ml. Chronic use of PPI's results in hypersecretion of gastrin due to prolonged suppression of acid secretion and is one cause of a false positive result on a serum gastrin laboratory. If gastric ulcers are severe and refractory to treatment, Zollinger-Ellison syndrome should be considered. Patients typically have a history of peptic ulcer disease and present with abdominal pain, heartburn, and diarrhea. A patient may present with jaundice if the gastrinomas compress the common bile duct.The initial test that should be ordered is a fasting serum gastrin level. If elevated, it should be followed by a secretin infusion test. Somatostatin-receptor scintigraphy is the imaging test of choice as it detects for primary or metastatic lesions. Treatment includes intravenous (IV) proton pump inhibitors and surgical resection. Zollinger-Ellison syndrome is also associated with multiple endocrine neoplasia (MEN) type 1. MEN 1 is also known as Werner's syndrome and presents with the 3 Ps: parathyroid tumors; pituitary tumors, including prolactinoma; and pancreatic endocrine tumors, including insulinomas, vipomas, glucagonomas, and Zollinger-Ellison syndrome. Osteopathic Pearl: Viscerosomatic reflexes are a type of somatic dysfunction caused by changes in the autonomic nervous system. They can be acute or chronic and are considered to be a somatic representation of visceral disease. When either branch of the autonomic nervous system (sympathetic or parasympathetic) overstimulates a particular organ, a reflex reaction occurs. The soma at the same level of the organ's autonomic innervation takes on characteristics of somatic dysfunction (TART). T5-T9 is where the sympathetic viscerosomatic reflex for the stomach, pancreas, and duodenum are located.

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it is high levels of zinc that have been associated with glucose intolerance. In addition, zinc supplementation in patients with diabetes may experience a worsening of serum glucose and subsequent elevations in HbA1c.

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Bottom Line: A middle cerebral artery stroke results in motor aphasia, paralysis of the contralateral face, arm, and leg, homonymous hemianopsia, and paralysis of the conjugate gaze to the opposite side.COMBANK Insight : Know the clinical symptoms associated with the occlusion of the major brain vessels. There are bound to be at least 1-2 questions on this in the exam.

true An anterior cerebral artery stroke would result in a contralateral lower extremity paralysis, and to a lesser degree, upper extremity weakness, urinary incontinence, and gait abnormalities. A posterior cerebral artery stroke would result in third nerve palsy, contralateral hemiplegia, homonymous hemianopsia, and visual neglect. Posterior inferior cerebellar artery stroke would result in vomiting, gait ataxia, truncal lateropulsion, and limb incoordination, along with an ipsilateral headache in the occipital region. A vertebrobasilar artery stroke would result in aphasia, dysphagia, gait abnormalities, and hemianopsia. The posterior circulation supplies the brainstem, which is particularly worrisome for "locked in" syndrome and involvement of vital functions.

For those who have loculated fluid or are unwilling or unable to receive frequent paracentesis, TIPS placement can also be considered. In the appropriately selected patient, TIPS is highly effective for preventing ascites recurrence by decreasing the activity of sodium-retaining mechanisms and improving renal function. Ongoing studies will determine whether TIPS might also provide a survival benefit. TIPS is most commonly performed under conscious sedation by an interventional radiologist. The portal system is accessed through the jugular vein, and the operator inserts a self-expanding shunt between the portal (high-pressure) and hepatic (low-pressure) veins. The ultimate goal of the procedure is to lower portal pressures to less than 12mm Hg, the level at which ascites begins to accumulate. Complications are relatively common and include hemorrhage (intrahepatic or intra-abdominal) and stent stenosis or thrombosis. Other important complications include hepatic encephalopathy and decompensation of liver or cardiac function. In this patient, TIPS would not be recommended as he has not yet tried diuretic therapy.

true Surgical shunting is the most invasive treatment for ascites and is used when medical management and the TIPS procedure fail. Given that sodium restriction has not helped this patient, continuing sodium restriction alone would not be the correct answer. According to current guidelines, ascites patients should be counseled to limit their sodium consumption to no more than 2 g/day. Because fluid passively follows sodium, a salt restriction without a fluid restriction is generally all that is required to decrease the amount of ascites. In patients with minimal fluid, the restriction of alcohol, NSAIDs, and salt may be all that is needed to control ascites formation adequately. This patient has alcoholic liver cirrhosis as evidenced by his examination showing signs of portal hypertension (caput medusa and ascites). Most patients with clinically apparent ascites will require diuretic therapy in addition to dietary sodium restriction. Diuretic therapy typically consists of treatment with spironolactone and furosemide in a ratio of 100:40 mg per day, with doses titrated upward as needed. Dietary sodium restriction and diuretic therapy is effective in approximately 90 percent of patients with cirrhosis and ascites. Concomitant treatment with both medications can mobilize moderate ascites more rapidly than if added sequentially. Also, using a combination of spironolactone and furosemide in a ratio of 100:40 mg usually maintains normokalemia. Spironolactone may be used alone only in severe alcoholic hepatitis with profound hypokalemia. Furosemide is still added once the potassium normalizes and potassium replacement is no longer needed.The response to diuretics should be carefully monitored on the basis of changes in body weight, laboratory tests, and clinical assessment. Patients on diuretics should be weighed daily; the rate of weight loss should not exceed 0.5 kg/day in the absence of edema and should not exceed 1 kg/day when edema is present. Serum potassium, blood urea nitrogen (BUN), and creatinine levels should be serially followed. In the setting of hyponatremia, diuretics should be stopped when the mean arterial pressure falls to 82 mmHg or below. Our patient is not markedly hyponatremic and is not hypotensive. It is safe and best practice to continue with diuretics for the treatment of his ascites. Making sure that potassium is repleted may also help treat hyponatremia.

Bottom Line: Erythema multiforme (EM) is a cutaneous skin eruption with classic targetoid and oral mucosal lesions most commonly caused by herpes simplex virus (HSV) and Mycoplasma pneumoniae. It is less commonly caused by drugs. All patients with EM should be evaluated for HSV infection

true The patient is suffering from erythema multiforme (EM), a cutaneous hypersensitivity inflammatory disease. This is evidenced by the vesicular rash on his lip and the prodrome of fever and malaise common to acute viral illnesses. The most common triggers for EM are herpes simplex virus (HSV) infection, followed by Mycoplasma pneumoniae infection. It occurs most often in young men. A prodrome of fever, malaise, and itching or burning at the site of the eruption can occur. Early lesions are red maculopapular spots and progress to the characteristic "targetoid" lesions. Targetoid lesions have a center blister surrounded by pale edema and a ring of erythema. Target lesions are the hallmark of EM, although they may not always be present. Lesions are usually symmetric and most commonly appear in a symmetrical distribution on the extensor surfaces of the acral extremities and subsequently spread in a centripetal manner. The lesions may be asymptomatic, but they also may present with itching and burning.Eruptions can also occur in the oral cavity and can often be associated with the vesicular lesions of HSV. EM can progress to toxic epidermal necrosis or Stevens-Johnson syndrome. If linked to an HSV infection, acyclovir can be prescribed to decrease recurrent rashes.

Lateral epicondylitis is an overuse injury primarily caused by microscopic tearing of the extensor carpi radialis brevis.

true This patient is suffering from lateral epicondylitis, which is also known as "tennis elbow." Lateral epicondylitis is an overuse injury of the forearm extensors and supinators and is common among amateur tennis players using an improper technique when hitting groundstrokes from the backhand side. Anatomically, this condition occurs as a result of microscopic tearing within the origin of the extensor carpi radialis brevis tendons and presents with pain at the lateral aspect of the elbow. Typical treatment is rest, ice, nonsteroidal anti-inflammatory drugs (NSAIDs), and a forearm strap over the proximal extensor carpi radialis tendon. Osteopathic manipulative treatment (OMT) includes myofascial release within the forearm and counterstrain to the affected muscles.

McCune-Albright syndrome is a rare form of gonadotropin-independent precocious puberty caused by a somatic mutation in the activating subunit of the G-coupled protein receptor responsible for follicle-stimulating hormone/luteinizing hormone signaling, leading to constitutive activation. This syndrome is characterized by a triad of precocious puberty, fibrous skeletal dysplasia, and café-au-lait spots. Enlarged bilateral ovaries are often seen on ultrasound. Clinically, cyclic vaginal bleeding precedes breast development. Accelerated bone growth and advanced bone maturation left untreated will compromise achievement of adult height. Viscerosomatic reflexes are a type of somatic dysfunction caused by changes in the autonomic nervous system. They can be acute or chronic and are considered to be a somatic representation of visceral disease. When either branch of the autonomic nervous system (sympathetic or parasympathetic) overstimulates a particular organ, a reflex reaction occurs. The soma at the same level of the organ's autonomic innervation takes on characteristics of somatic dysfunction (TART). T10-T11 is where the sympathetic viscerosomatic reflex for the ovary is located. Recall that the parasympathetic innervation related to the ovaries is carried via CN X (Vagus nerve).

true 11-beta hydroxylase is a minor form of congenital adrenal hyperplasia. 21-hydroxylase is the classic form of congenital adrenal hyperplasia. Mutations in this steroidogenic enzyme result in accumulation of aldosterone and cortisol and shifts production toward androgen synthesis. Clinically, early onset results in masculinization of external female genitalia leading to ambiguous genitalia, whereas late onset results in virilization at the time of puberty that may mimic polycystic ovary syndrome. Exogenous hormone exposure can have similar clinical manifestations; however, McCune-Albright syndrome may be distinguished from exogenous hormone exposure by the presence of non-gynecologic manifestations resulting from expression of the mutated receptor in various tissues, leading to the development of bone and skin lesions. Failed migration of GnRH neurons is the major etiology of Kallman syndrome, a form of congenital hypogonadotropic hypogonadism. Kallman syndrome is characterized by delayed puberty and is often accompanied by anosmia.

Bottom Line: Right upper quadrant ultrasound is the initial radiographic test of choice for evaluating the liver and biliary tree in a stable patient with concern for biliary cholic and gallstones

true : An international normalized ratio (INR) would not be useful since the patient is not on warfarin and has no signs or symptoms suggestive of coagulopathy. This is a stable outpatient, and given that the most likely diagnosis is biliary cholic, there is no acute indication for surgery, and INR would not be needed.

The US Preventative Task Force (USPSTF) recommends screening for cervical cancer via Pap smear once every 3 years in asymptomatic immunocompetent women from ages 21-29.The USPSTF recommends for women ages 30 to 65 years to use one of the following screening options:1. screen every 3 years with Pap smear alone2. screen every 5 years with high-risk human papillomavirus (hrHPV) testing alone3. screen every 5 years with hrHPV testing in combination with Pap smear (cotesting).It would also be reasonable to offer her sexually transmitted disease screening and get an updated pulmonary function test in light of her sparse routine medical care in the recent past. The patient noted increased use of her rescue inhaler during your history taking. In light of her sparse past medical care, it would be reasonable to get an updated pulmonary function test. The most common pulmonary function test ordered for a patient with a history of asthma is spirometry. Spirometry measures the patient's degree of reversible airflow obstruction before and after the administration of a bronchodilator such as albuterol. It is recommended that patient's with asthma not be treated without pulmonary function tests as there are many other causes of wheezing and shortness of breath which must be considered if testing is normal.

true : This patient has not had regular medical care in over three years so she is due for a Pap smear at today's exam. Offering screening for sexually transmitted infections should always be considered. An updated pulmonary function test would also be appropriate to optimize her asthma medication management.

Bottom Line: A complex ovarian mass with high-risk features in a postmenopausal patient needs to be surgically removed. Surgery is used both for diagnosis and treatment. There are no noninvasive options to exclude malignancy at this time.

true A complex ovarian mass in a postmenopausal patient should be removed surgically. The transvaginal ultrasound shows high-risk features (thick, nodular septations). There is no noninvasive biopsy options for ovarian lesions. Tumor markers should be ordered prior to intervention (CA-125) and computed tomography (CT) scans to further characterize disease. The patient will need surgery for both diagnosis and treatment. Staging is performed at the time of the operation. The differential diagnosis of an adnexal mass depends on the clinical scenario. Urgent conditions include ectopic pregnancy (positive pregnancy test without intrauterine pregnancy), torsion (acute onset pain with no flow on doppler ultrasound), or Tuboovarian abscess [fever, history of pelvic inflammatory disease (PID)]. Patients can also have simple benign cysts and malignancy. Ultrasound features are important to distinguish between the two. High-risk features include solid components, thick/nodular septations, peritoneal implants, and ascites.

Bottom Line: Diagnosis of diabetes mellitus can be confirmed using multiple laboratory tests including, but limited to, a hemoglobin A1C (HbA1C) >6.5% and fasting blood glucose >126 mg/dL on multiple occasions. Monitoring blood glucose and treatment success is done by measuring HbA1C, with levels of <7% being the threshold for the general population. COMBANK Insight : Monitoring blood glucose in patients with diabetes occurs in the outpatient and inpatient settings. One of the most notable studies is the ACCORD trial published in 2008 in the New England Journal of Medicine. This study demonstrated the increased mortality in patients treated with strict glycemic control. For completeness, glucose control in the inpatient intensive care setting has also been evaluated. A keystone study was the NICE-SUGAR trial published in the New England Journal of Medicine, which also demonstrated that strict glycemic control (81-108 mg/dL) led to increased mortality as compared to more liberal glycemic control, as defined as ≤180 mg/dL.These studies and the subsequent recommendations influenced by them are paramount for both academic and clinical purposes.

true A target hemoglobin A1C (HbA1C) for a young patient with diabetes mellitus (DM) is <7%. This patient is presenting with symptomatic DM. Diagnosis can be confirmed by the demonstration of fasting plasma glucose (FPG) ≥126 mg/dL, 2-hour plasma glucose ≥200 mg/dL, an HbA1C ≥6.5%, or a random blood glucose value of >200 mg/dL with the presence of symptoms including polyuria and polydipsia. Glycemic control remains the cornerstone of treatment for patients with DM and can be achieved in multiple ways both through lifestyle and pharmacotherapy. When assessing the success of therapy, the goal is defined as an HbA1C <7% in otherwise healthy patients in whom the risk of hypoglycemia is low. This threshold has been adopted and endorsed by multiple agencies including the American Diabetes Association and the American College of Physicians. A notable exception to this limit may be applied to elderly individuals (age >80 years) with limited life expectancy (ie, <10 years) in whom the risks of hypoglycemia outweigh potential long-term benefits from strict glucose control. In this population, a goal HbA1C of <8% may be reasonable.

Patients with Crohn's disease are at an increased risk for developing ankylosing spondylitis.

true Ankylosing spondylitis is seen in up to 10% of patients suffering from inflammatory bowel disease (IBD) and presents with low back pain and stiffness. Up to 75% of patients with IBD and ankylosing spondylitis are HLA-B27 positive. There are numerous other systems which can be affected by Crohn's disease. Some other notable complications of Crohn's disease include uveitis, scleritis, primary sclerosing cholangitis, erythema nodosum, pyoderma gangrenosum, calcium oxalate renal stones, vitamin B12 deficiency, interstitial lung disease, and venous thromboembolism due to hypercoagulability.

Bottom Line: Thyroglossal duct cysts can be found in the subhyoid portion of the tract and most present as a midline swelling. Typically, the cyst will move upwards on protrusion of the tongue, given its attachment to the embryonic duct, as well as on swallowing, due to attachment of the tract to the foramen cecum.

true A thyroglossal cyst is a fibrous cyst that forms from a persistent thyroglossal duct. Thyroglossal cysts can be defined as an irregular neck mass or a lump which develops from cells and tissues left over after the formation of the thyroid gland during developmental stages. Thyroglossal cysts are the most common cause of midline neck masses and are generally located caudal to (below) the hyoid bone. These neck masses can occur anywhere along the path of the thyroglossal duct, from the base of the tongue to the suprasternal notch. Other common causes of midline neck masses include lymphadenopathy, dermoid cysts, and various odontogenic anomalies. Thyroglossal cysts develop at birth. Many diagnostic procedures may be used to establish the degree of the cyst. The thyroglossal tract arises from the foramen cecum at the junction of the anterior two-thirds and posterior one-third of the tongue. Any part of the tract can persist, causing a sinus, fistula or cyst. Most fistulae are acquired following rupture or incision of the infected thyroglossal cyst. A thyroglossal duct cyst can usually be diagnosed by history and physical alone. To get credit for this question you need to have selected a review of systems, physical exam, and referral to ENT. These are the steps with which you should be aware. An MRI is expensive and not indicated and ordering one would be incorrect. Additionally, ordering a fine needle aspiration before you have imaging confirmation would also be incorrect. A detailed history is always the starting point for any kind of medical investigation. A physical exam is always required before more invasive testing. Thyroglossal cysts develop at birth. The thyroglossal tract arises from the foramen cecum at the junction of the anterior two-thirds and posterior one-third of the tongue and the cyst will move with protrusion of the tongue or with swallowing. Many diagnostic procedures may be use to establish the degree of the cyst, though diagnosis can usually be established with history and physical exam alone. Ultrasound could help delineate amongst possible differential diagnoses while being inexpensive and easy to obtain in the office. It also has the advantage of not requiring ionizing radiation and is the preferred initial imaging modality in children. Most people will go on to require a CT scan due to its ability to better evaluate the cyst as well as any associated structures or tracts. This is one of the rare questions where referral is appropriate for both monitoring and eventual surgical excision.

This patient should be treated with antibiotics as there is evidence of sepsis with fever and tachycardia with an elevated WBC count. Ciprofloxacin and metronidazole are appropriate choices for outpatient management. Given worsening resistance to fluoroquinolones, many hospitals now request the use of alternate antibiotics. Ceftriaxone is a third-generation cephalosporin and is appropriate in this case as it covers all standard gut microbiota which could be contributing to infection except for anaerobes which are covered by metronidazole. Given continued vomiting and signs of infection, the patient should be admitted to the hospital and made nil per os until the vomiting has stopped and they are ready to be started on a trial of diet. The patient has continued vomiting and would be unable to tolerate oral antibiotics at home. He should be admitted to a medical ward where he can receive IV antibiotics and fluids until he can tolerate oral intake. This can generally take 1-2 days in severe disease. Since the patient has continued to vomit and has an elevated heart rate, he will continue to benefit from IV fluid resuscitation both for his inability to eat and for treatment of sepsis.Diverticulitis should be treated with broad-spectrum antibiotics in most cases (though there are reports of treatment of very mild, uncomplicated diverticulitis without antibiotic therapy by using bowel rest alone.) The antibiotics should cover gut microorganisms and are generally continued for 7-10 days depending on severity and clinician preference. Patients who cannot tolerate oral intake, have signs of sepsis, are elderly, or fail outpatient treatment may require hospital admission, as in this case.

true After recovering from acute diverticulitis, any patient without a recent colonoscopy should consider endoscopic evaluation for malignancy as well as possible underlying inflammatory bowel disease. In addition, after an acute episode of diverticulitis, the patient should be advised to eat a high-fiber diet as studies have shown that high-fiber intake is associated with fewer symptomatic episodes of diverticulitis. The most important recommendation to receive credit for this question is to recommend colonoscopy as to miss this could potentially miss an underlying malignancy. Patients with diverticulitis can be screened for colon cancer/mass as a cause of their event several weeks after their symptoms have resolved. This is more important if they have never had an episode of diverticulitis in the past and have never had colon cancer screening, as in this patient. This patient also has a family history of colon cancer and is over 50 years of age. He should have a colonoscopy performed.

All patients who present with signs of fecal impaction should receive a digital rectal examination. Digital examination of the rectum can be both diagnostic and therapeutic in this scenario. It can provide valuable information regarding the presence/absence of anorectal masses, allow the assessment of sphincter tone, and assess for gross blood or occult bleeding by checking the stool guaiac. Digital examination will also provide insight regarding stool quantity and consistency. Disimpaction is the preferred treatment over other modalities of therapy such as warm water enemas. Further work-up is unnecessary from a cost-analysis perspective and should be reserved for patients who don't respond to conservative therapy.

true All patients who present with signs of fecal impaction should receive a digital rectal examination. Digital examination of the rectum can be both diagnostic and therapeutic in this scenario. It can provide valuable information regarding the presence/absence of anorectal masses, allow the assessment of sphincter tone, and assess for gross blood or occult bleeding by checking the stool guaiac. Digital examination will also provide insight regarding stool quantity and consistency. Disimpaction is the preferred treatment over other modalities of therapy such as warm water enemas. Further work-up is unnecessary from a cost-analysis perspective and should be reserved for patients who don't respond to conservative therapy.

Bottom Line: Heartburn is a normal consequence of pregnancy and is initially treated with lifestyle modifications, like raising the head of the bed at night.

true Although awakening with coughing is seen in both asthma and gastroesophageal reflux (GERD), symptoms from spicy foods implies GERD. Heartburn is a normal consequence of pregnancy. Common symptoms include nighttime awakening with coughing spells due to a tiny amount of esophageal reflux. Initial treatment is aimed at lifestyle modifications, including avoiding trigger foods, eating smaller meals, and raising the head of the bed at night.

Bottom Line: Victims of intimate partner violence can have varying presentations. It is important to recognize the common traits portrayed by these victims so that you may be able to identify them in your practice of medicine.Intimate partner violence requires interdisciplinary collaboration among healthcare workers, which has been shown to provide positive treatment outcomes.COMBANK Insight : Most barriers to reporting include a lack of awareness of intimate partner violence, downplaying of the situation, fear of partner retaliation, concern for custody conflicts, shame, embarrassment, and a reluctance to talk to male physicians. Interdisciplinary collaboration among healthcare workers was a predictor of positive treatment outcomes. Included were more accurate assessments of past history, more descriptive emotional symptoms as displayed by the victims, and written documentation of recommendations concerning intervention and linkage to community resources.

true An overly attentive or verbally abusive partner is a sign of intimate partner violence. The clinician should be suspicious if the partner answers questions for the patient or refuses to leave the examination room, and the clinician should find a way to question the patient alone. Partner reluctance to leave the patient alone is an important sign of possible intimate partner violence.Intimate partner violence describes a serious, preventable public health problem that affects millions of Americans. It can be described as physical, sexual, or psychological harm by a current or former partner or spouse. Intimate partner violence is a serious problem that can have lasting harmful effects on individuals, families, and communities. The goal for intimate partner violence prevention is simple: to stop it from happening in the first place. However, the solutions are just as complex as the problem. Emotional abuse is more difficult to discern. Communication and awareness are advocated.

The most likely cause of dysphagia in an AIDS patient is Candida esophagitis and can be treated empirically. If this patient was to undergo EGD, it would show pseudohyphae. Pseudohyphae are a result of budding yeast where the cells remain attached, giving the appearance of branching filaments. They are diagnostic for Candida.

true Answer A: CMV is identified by the presence of very large cytomegalic cells with enlarged nuclei that contain a violaceous intranuclear inclusion surrounded by a clear halo. This, like HSV, more commonly causes odynophagia without dysphagia.Answer B: Ground glass intranuclear Cowdry type A inclusion bodies are associated with the herpes virus. HSV more commonly causes odynophagia without dysphagia.Answer C: Excess eosinophils is a nonspecific sign of chronic esophageal inflammation. This can be seen in eosinophilic esophagitis, which is more common in healthy, middle-aged men. It presents with dysphagia.Answer E: Septate hyphae orientated at acute angles is the classic description of Aspergillus and generally does not cause esophageal infections.

Bottom Line: The utility of imaging in patients with cutaneous pathology may be targeted based off of known associations with characteristic skin lesions. Dermatomyositis is associated with an increased incidence of cancer.COMBANK Insight : An astute clinician can seem a hero when he or she recognizes one of many characteristic cutaneous manifestations associated with systemic neoplasms orsyndromes. Knowing the potentially involved organs or diseases is paramount in early and appropriate screening. While select cancers have been shown to be over represented in patients with dermatomyositis, the association with ovarian cancer is frequently presented across multiple tests through medical school and residency. This association is a must know.

true Answer A: Cardiac MRI is a useful screening test if there is a concern for soft tissue and/or depositional disease of the heart. Examples of cutaneous syndromes with cardiac neoplasms include angiofibromas/adenoma sebaceum and collagenomas (shagreen patch) with cardiac rhabdomyomas as encountered in tuberous sclerosis, or the epitheliod blue nevi, ephelides, and atrial myxoma associated with Carney's complex. Depositional disease may occur in systemic amyloidosis with corresponding cutaneous amyloid deposits.

This patient is presenting with concern for a deep venous thrombosis (DVT). Risk factors include immobility, hypertension, and smoking, among others. The standard treatment for unprovoked DVT includes at least 3 months of anticoagulation with a recommendation for lifelong extension in patients with a low bleeding risk. The choice of the anticoagulant depends on the health of the patient and medical comorbidities. For most nonpregnant patients who do not have severe renal insufficiency or active cancer, oral anticoagulants are recommended. At this time, warfarin remains the prefered anticoagulant for patients with severe renal insufficiency. Warfarin requires multiple office visits for international normalized ratio (INR) monitoring and has a higher bleeding risk when compared with direct oral anticoagulants; however, antidotes for warfarin-related bleeding are more readily available. Also note that Warfarin is not dialyzable, which is another indication for careful monitoring. It should be noted, however, that more research has begun to show that apixaban (Eliquis) may be quite safe in the setting of end-stage renal disease and, within a few years, may be more widely used and recommended. Currently, however, most experts avoid use in ESRD requiring hemodialysis for the treatment of thromboembolic disease, though a recent study has shown good efficacy for stroke-prevention in atrial fibrillation.

true Answer A: Dabigatran (Pradaxa) is a direct thrombin inhibitor. It is not recommended in patients with end-stage renal disease (ESRD). Patients receiving hemodialysis and patients with CrCl < 30 mL/minute were excluded from clinical trials. It does not require routine laboratory monitoring and dose adjustments.Answer B: Fondaparinux is an alternative to low-molecular-weight heparin that is used in patients with heparin-induced thrombocytopenia. It is also contraindicated in patients with severe renal insufficiency (creatinine clearance [CrCl] < 30 mL/min).Answer C: Low-molecular-weight heparin (LMWH) is the preferred agent for those in whom treatment with one of the oral agents is not feasible (eg, patients with poor or no oral intake). LMWH has not been FDA approved for use in dialysis patients. Its elimination is primarily via the renal route. Serious bleeding complications have been reported with use in patients who are dialysis dependent or have severe renal failure.Answer D: Rivaroxaban (Xarelto) is another direct thrombin and factor Xa inhibitor. It is one of the first-choice oral anticoagulants for long-term anticoagulation in most nonpregnant patients who do not have severe renal insufficiency or active cancer. It is not indicated in patients with end-stage kidney disease. It does not require routine laboratory monitoring and dose adjustments.

In adults, the most common organisms that cause acute epiglottitis are Streptococcus pneumoniae, Haemophilus influenzae, H. parainfluenzae, and group A streptococci. Less common infectious etiologies include other bacteria (Staphylococcus aureus, mycobacteria, Bacteroides melaninogenicus, Enterobacter cloacae, Escherichia coli, Fusobacterium necrophorum, Klebsiella pneumoniae, Neisseria meningitidis, Pasteurella multocida), herpes simplex virus (HSV), infectious mononucleosis, Candida (in immunocompromised patients), and Aspergillus (in immunocompromised patients).The most common organism in adults is Streptococcus pneumoniae. In children, H. influenzae (strains not found in the immunization) is still the most common organism. The treatment for epiglottitis is with a third-generation cephalosporin and with the addition of vancomycin in areas with a high prevalence of MRSA.

true As mentioned above, the most common cause for epiglottitis in adults is Streptococcus pneumoniae. Noninfectious causes of epiglottitis include thermal causes including those associated with crack cocaine and marijuana smoking, caustic insults, and foreign body ingestion.

Grief is the distress that occurs in response to bereavement. Bereavement is the situation in which a loved one has died. This patient is dealing with acute grief as a result of her father's death. Acute grief typically does not require treatment. Support from family, friends, and clergy is usually sufficient to manage the pain of acute grief, but counseling and support groups are also appropriate. Bereaved patients who seek help from clinicians typically can be managed with support, which includes empathic listening, information about the wide range of typical grief symptoms that can occur, reassurance, monitoring, and referral to counseling or support groups. Encouraging patients to maintain regular patterns of activity, sleep, exercise, and nutrition may also help patients adapt to bereavement.

true Bottom Line: Acute grief typically does not require treatment. Support from family, friends, and clergy is usually sufficient to manage the pain of acute grief, but some patients need more and will benefit from counseling or support groups. Encouraging patients to maintain regular patterns of activity, sleep, exercise, and nutrition may also help patients adapt to bereavement. Writing about grief and negative thoughts, as well as positive events and thoughts, does not appear to improve grief or depressive symptoms (eg, anorexia, insomnia, and anhedonia), although it may reduce loneliness and improve positive mood.

This patient is presenting with one blood pressure reading and proteinuria, which are suggestive (need 2 abnormal blood pressure readings to diagnose preeclampsia) for preeclampsia. Preeclampsia is diagnosed when a pregnant woman develops: Blood pressure ≥ 140 mm Hg systolic or ≥ 90 mm Hg diastolic on two separate readings taken at least four to six hours apart after 20 weeks' gestation in an individual with previously normal blood pressure.In a woman with essential hypertension beginning before 20 weeks' gestational age, the diagnostic criteria are: An increase in systolic blood pressure (SBP) of ≥ 30mmHg or an increase in diastolic blood pressure (DBP) of ≥ 15mmHg. Proteinuria is defined as: ≥ 0.3 grams (300 mg) or more of protein in a 24-hour urine sample, or a SPOT urinary protein to creatinine ratio ≥ 0.3, or a urine dipstick reading of 1+ or greater (dipstick reading should only be used if other quantitative methods are not available).In addition, suspicion for preeclampsia should be maintained in any pregnancy complicated by elevated blood pressure, even in the absence of proteinuria. Ten percent of individuals with other signs and symptoms of preeclampsia and 20% of individuals diagnosed with eclampsia show no evidence of proteinuria. In the absence of proteinuria, the presence of new-onset hypertension (elevated blood pressure) and the new onset of one or more of the following are suggestive of the diagnosis of preeclampsia: Evidence of kidney dysfunction (oliguria, elevated creatinine levels), impaired liver function (impaired liver function tests), thrombocytopenia (platelet count < 100,000/microliter), pulmonary edema, ankle edema pitting type, and/or cerebral or visual disturbances. This patient has one elevated blood pressure and proteinuria, suggesting that she may be at increased risk of preeclampsia if her next blood pressure continues to be elevated.

true Bottom Line: Adolescent patients should be interviewed alone without a parent for at least a portion of the visit. For any portion of the visit but especially the physical exam, providers should strongly consider having a parent or other chaperone present.

This patient is presenting with a malar rash, fatigue, and weight loss associated with pancytopenia and proteinuria, which are all signs of systemic lupus erythematosus (SLE). SLE is a systemic autoimmune disease. SLE most often affects the heart, lungs, kidneys, skin, blood vessels, liver, and nervous system. Chronic signs and symptoms include fever, malaise, joint pain, myalgias, the classic malar rash, and photosensitivity. The initial test for lupus should include an antinuclear antibody (ANA) test, which has a sensitivity of 99% and specificity of 49%. ANA testing and anti-extractable nuclear antigen (anti-ENA) form the mainstay of serologic testing for SLE. Several techniques are used to detect ANAs. Clinically, the most widely used method is indirect immunofluorescence (IF). The pattern of fluorescence suggests the type of antibody present in the patient's serum. Direct immunofluorescence can detect deposits of immunoglobulins and complement proteins in the patient's skin. When skin not exposed to the sun is tested, a positive direct IF (the so-called lupus band test) is evidence of SLE. ANA screening yields positive results in many connective tissue disorders and other autoimmune diseases and may occur in normal individuals.

true Bottom Line: Antinuclear antibodies are the most sensitive marker for systemic lupus erythematosus and should be checked first when this diagnosis is suspected. The most specific antibody to test is the anti-dsDNA antibody.

This patient's BMI is 28.8 and she has comorbid factors relating to her being overweight including diabetes mellitus and hyperlipidemia. The following weight definitions are important:Overweight is defined as a BMI of 25 to 29.9 kg/m2; obesity is defined as a BMI of ≥30 kg/m2; severe obesity is defined as a BMI ≥40 kg/m2 (or ≥35 kg/m2 in the presence of comorbidities).Candidates for drug therapy include those individuals with a body mass index (BMI) ≥30 kg/m2, or a BMI of 27 to 29.9 kg/m2 with comorbidities, who have not met weight-loss goals (loss of at least 5 percent of total body weight at three to six months) with a comprehensive lifestyle intervention. Given this patient has a BMI between 27 and 29.9 and she has comorbid factors including diabetes mellitus and hyperlipidemia and failure to manage weight with lifestyle modifications, this patient would qualify for medical management. Liraglutide is a chemically modified version of human GLP-1. It is associated with a significant reduction in weight (2 to 4 kg). This is the preferred medication for overweight and obese patients with type 2 diabetes where its side effects, need for injections, and expense are balanced by improved glycemia and weight loss. This patient has uncontrolled diabetes with a high HbA1C of 11% and would benefit from using liraglutide. Some of the adverse effects of this medication include gastrointestinal side effects, including nausea and vomiting are common. Other side effects include diarrhea, low blood sugar, and anorexia. Serious but less common side effects include pancreatitis, gallbladder disease, and renal impairment. It is important to watch for these side effects while on this medication.

true Bottom Line: Candidates for drug therapy include those individuals with a body mass index (BMI) ≥30 kg/m2, or a BMI of 27 to 29.9 kg/m2 with comorbidities, who have not met weight-loss goals (loss of at least 5 percent of total body weight at three to six months) with a comprehensive lifestyle intervention.

Four questions need to be answered when assessing capacity:- Can the patient reach a decision when presented with multiple options?- Does the patient have the ability to understand the information presented?- Does the patient appreciate the situation and the consequences that may occur based on his or her decision?- Does the patient have the ability to logically sort through the options and information presented?If patients do not have capacity, they are unable to decide for themselves what the next best course of action is in their medical care, and you will need to collaborate with next of kin and make a decision together for the best interest of the patient.The patient in this case is septic and delirious as a result. She does not have the capacity to refuse treatment at this time. It would be a good idea to involve the patient's daughter in this decision, but you have to do the right thing for the patient if she does not have the capacity to make that decision herself.

true Bottom Line: Capacity is determined by a physician; competency is determined by the courts. If a patient does not have capacity to refuse treatment, you must do what is best for the patient.COMBANK Insight : Calling a consult is almost never the correct choice on the COMLEX. Remember to take the exam from the standpoint of the primary care provider.

Based on the NYHA functional class, the patient likely is class III. Class one is described as CHF symptoms causing no limitation during ordinary activity. Class II is described as CHF causing slight limitation by shortness of breath and/or fatigue during moderate exertion or stress. Class III symptoms are caused by minimal exertion that interfere with normal daily activity. Class IV symptoms are characterized by an inability to carry out any physical activity; these patients typically have marked neurohumoral activation and muscle wasting.NOTE: Do not get the classes of heart failure confused with the stages. The stages are A, B, C, and D and are used to assess risk for developing heart failure and/or progression and therapeutic choices. Stage A means the patient has a risk for heart failure but no structural heart disease or symptoms. Stage B means the patient has structural heart disease but no symptoms of heart failure. Stage C is heart disease with symptoms of heart failure, and stage D is refractory heart failure requiring advanced interventions such as transplant, inotropes, or left ventricular assist device.

true Bottom Line: Class III symptoms are caused by minimal exertion that interferes with normal daily activity. The NYHA classifications are used often to categorize patients in heart failure trials, and different therapeutic agents have been studied for different classes of heart failure. Therefore, it is important to know and understand these distinctions.

This patient presents with signs and symptoms of hyperthyroidism. This is not an uncommon presentation in a 27-year-old male. Patients with hyperthyroidism commonly present with palpitations (sometimes atrial fibrillation), anxiety, weakness, weight loss, tremor, and increased perspiration. On physical exam, the patient will often have lid lag, tachycardia, rapid speech, and systolic hypertension. The patient typically presents with tremor, hyperreflexia, and proximal muscle weakness. The initial test to order when working up a patient for hyperthyroidism is a thyroid-stimulating hormone (TSH) level. In patients with hyperthyroidism, the TSH level is always low. In patients with overt hyperthyroidism, the level is typically <0.05 mU/L. If you check a TSH level on a patient and it is normal, then it is very unlikely that the patient has hyperthyroidism.

true Bottom Line: In a patient with signs and symptoms of hyperthyroidism, the best initial test is the serum thyroid-stimulating hormone level.COMBANK Insight : The COMLEX utilizes videos that show physical exam findings with increasing frequency. It is important that you continue to learn the physical exam findings of different ailments.

Bottom Line: The video shows a negative Babinski sign, which means the patient does not have an upper motor neuron lesion.

true The patient has a negative Babinski sign, as the patient's toes are flexing. This is considered a normal plantar reflex, which means the patient's right lower extremity weakness is not being caused by an upper motor neuron lesion. However, considering the patient's history of right-sided stroke, he may very well have a positive Babinski sign (wherein his big toe will point upward) noted on the left side.

Prognosis of burn victims is directly related to body surface area (BSA) involved. Because this is easily calculated and varies by age, the topic is highly tested. Superficial involvement is not included in the calculation, and therefore, it only includes areas of superficial partial-thickness, deep partial-thickness, and full-thickness burns. For adults, measurement can be generalized by the "rule of nines," whereby various body parts are made up of multiples of 9. Head: 9% EACH complete arm: 9% EACH complete leg: 18% Anterior trunk (abdomen and chest): 18% Posterior trunk (upper and lower back): 18% Genitals: 1% The assessment of children is different because they have larger heads and smaller lower extremities. This can be referenced in the Lund-Browder chart. This chart varies by age and can be complicated because it is broken up by multiple anterior and posterior segments of each extremity and trunk. This is summarized for a child at 5 to 10 years old: Anterior AND posterior head: 13% Anterior AND posterior neck: 2% Anterior trunk (abdomen and chest): 13% Posterior trunk (upper and lower back): 13% Anterior AND posterior of EACH arm and hand: 9.5% EACH anterior thigh, leg, and foot: 8.25% EACH posterior glute, thigh, and leg: 9% Genitals: 1% A quick estimate for small areas of involvement uses the palm method. This provides an estimate using the patient's palm including fingers, where each area covered by 1 palm surface represents 1% of total BSA

true Bottom Line: In burn victims, the body surface area burned is highly tested because it affects to both prognosis and treatment. Adult calculation is more straightforward and therefore highly testable. Burn severity is as follows: Superficial: Superficial burns with involvement only of the epidermal layer of skin Superficial partial-thickness: Partial-thickness burns involving the epidermis and portions of the dermis Deep partial-thickness: Full-thickness burns extending through all layers of the dermis Full-thickness: Burns involving skin and/or muscle/bone The location of a burn often directs treatment. Burns on the face, hands, feet, and genitalia as well as large burns in other areas of the body and those associated with inhalational injury are often referred to burn centers.

This case is most consistent with an ectopic pregnancy. An ectopic pregnancy is defined as any pregnancy that is outside of the uterine cavity. The most common site is the fallopian tube. The hCG level is high enough to detect an intrauterine pregnancy by ultrasound, and no intrauterine gestational sac is concerning for an underlying ectopic pregnancy. Pelvic inflammatory disease (PID) is a risk factor for ectopic pregnancy because it can damage the fallopian tubes. PID can be caused by chlamydia or gonorrhea infection, which leads to scarring of the fallopian tubes. Scarring within the fallopian tubes leads to decreased motility of the cilia that are normally responsible for helping the egg reach the uterus. If eggs are not able to reach the uterus, they can implant within the fallopian tube, leading to an ectopic pregnancy.

true Bottom Line: Laparoscopy is the treatment of choice for a suspected non-ruptured ectopic pregnancy greater than 3.5 cm.COMBANK Insight : When answering questions that are linked, always keep your diagnosis consistent. Do not stagger your answers, even if you are guessing. This case is extremely suspicious for ectopic pregnancy. For hemodynamically unstable patients, immediate surgery is required. For hemodynamically stable patients, closely following serial beta-hCG levels is recommended with or without ultrasound. Methotrexate can be used in small, less than 3.5 cm, unruptured ectopics. Laparoscopic surgery is the treatment of choice for a non-ruptured ectopic pregnancy larger than 3.5 cm, as in this case salpingectomy or salpingostomy may be useful.

An electrocardiogram (ECG) reveals unexpected dropped beats without a change in the PR interval. This can be used to distinguish it from Mobitz type I AV block and third-degree AV block. In most cases, the treatment for Mobitz type II AV block is a pacemaker.

true Bottom Line: Mobitz type II atrioventricular (AV) block usually results from fibrotic disease of the conduction system, mainly affecting the His-Purkinje system. The pathology is almost always below the level of the AV node. This is contrasted to Mobitz I or Wenckebach, where the location of conduction failure is actually within the AV node in the majority of cases. A third-degree block can occur anywhere along the conduction system. If it occurs in the His-Purkinje system or the AV node, then the escape rhythm will generally appear narrow on ECG. If it occurs more distally, then the rhythm will be a ventricular escape and will be wider and slower.

Neuroleptic malignant syndrome (NMS) is a life-threatening neurological emergency. As indicated by the name, it is most commonly associated with neuroleptic medications such as haloperidol, chlorpromazine, risperidone, etc. Symptoms include extreme muscular rigidity, mental status changes, hyperthermia, tachycardia, tachypnea, and profuse diaphoresis.

true Bottom Line: NMS typically causes markedly elevated serum creatine kinase, due to muscle cell damage from muscle rigidity. Other laboratory findings include metabolic acidosis, hyperkalemia, leukocytosis, and myoglobinuria.

Obsessive-compulsive disorder (OCD) is characterized by recurrent intrusive thoughts, images, or urges (obsessions) that typically cause anxiety or distress, and by repetitive mental or behavioral acts (compulsions) that the individual feels driven to perform, either in relation to an obsession or according to rules that he or she believes must be applied rigidly or to achieve a sense of "completeness." OCD typically starts in childhood or adolescence, persists throughout a person's life, and produces substantial impairment in functioning due to the severe and chronic nature of the illness.DSM-V criteria include the presence of obsessions, compulsions, or both, examples below:Obsessions: Recurrent and persistent thoughts, urges, or images that are generally intrusive and unwanted, and can cause anxiety or distress. The individual attempts to ignore or suppress the thoughts, urges, or images, with some other thought or action (ie, by performing a compulsion). Compulsions: Repetitive behaviors (eg, hand washing, checking) or mental acts (eg, praying, counting) performed in response to an obsession to reduce stress and anxiety - The obsessions or compulsions are time-consuming (eg, take more than one hour per day) or cause clinically significant distress or impairment - The obsessive-compulsive symptoms are not attributable to the physiological effects of drugs or another medical condition.- The disturbance is not better explained by the symptoms of another mental disorder

true Bottom Line: Obsessive-compulsive disorder (OCD) is characterized by recurrent intrusive thoughts, images, or urges (obsessions) that typically cause anxiety or distress, and by repetitive mental or behavioral acts (compulsions) that the individual feels driven to perform, it is important to understand the diagnostic criteria

Bottom Line: Endoscopic retrograde cholangiopancreatography is the best way to relieve bile duct obstruction in cholangitis.

true Endoscopic retrograde cholangiopancreatography (ERCP) allows for confirmation of the diagnosis and therapeutic intervention. The most likely etiology of cholangitis is a stone in the common bile duct. The most important step in management is to relieve the obstruction. Antibiotics and fluid resuscitation are important initial steps, but stone removal is required to treat the patient. Cholecystectomy is then usually performed before discharge to prevent further episodes based on patient condition.

Bottom Line: Callus formation on the back of the index and long fingers is referred to as the Russell sign and occurs secondary to self-inflicted vomiting in patients with bulimia nervosa.COMBANK Insight : Make sure you take time to review some of the more popular (and unpopular, as in the above case) physical exam signs that are associated with specific diagnoses. Here is a list of 10 of the most frequently tested signs on COMLEX. Know them!1) Murphy sign - acute cholecystitis2) McBurney point - acute appendicitis3) Chvostek sign - hypocalcemia4) Homans' sign - deep vein thrombosis5) Courvoisier sign - pancreatic cancer6) Rebound tenderness - peritonitis7) Chandelier sign - pelvic inflammatory disease8) Kernig sign - meningitis9) Brudzinski sign - meningitis10) Waddell signs - malingering

true Bottom Line: Orthopnea, PND, JVD, peripheral edema, shortness of breath, and cool extremities are signs and symptoms of patients with decompensated heart failure.COMBANK Insight : Know the signs and symptoms of CHF. It is a high yield topic on the COMLEX.

This is a classic presentation of Guillain-Barre syndrome (GBS), which typically presents with symptoms of dysesthesias of the fingers and lower extremity muscle weakness 2 to 4 weeks following a respiratory or gastrointestinal illness. The patient may complain of weakness that progresses over hours to days involving the arms, trunk, and muscles of respiration (as in this case). The patient's oxygen saturation is suboptimal and indicates hypoxia from diaphragmatic involvement and resultant respiratory insufficiency. It would be a good idea to send the patient to the emergency department to get an arterial blood gas and consider intubation. In general, the threshold for intubation in GBS patients should be relatively low.

true Bottom Line: Plasmapheresis and intravenous immunoglobulin have been shown to be highly beneficial in patients diagnosed with Guillain-Barre syndrome.COMBANK Insight : Questions pertaining to the diagnosis and management of Guillain-Barre syndrome are seen routinely on COMLEX. This subject should rank among your "must knows" for the exam.

In a patient with variant angina, the drug of choice is a calcium channel blocker (CCB), which decreases the coronary artery vasospasm typical of this disease. Nitrates have also been shown to be helpful for symptom relief.

true Bottom Line: Risk factors for cervical cancer include early age at coitus, early child-bearing, multiple sexual partners, smoking, and immunodeficiency.COMBANK Insight : Because many women are screened routinely, the most common finding is an abnormal Papanicolaou test result. Typically, these patients are asymptomatic. Clinically, the first symptom is abnormal vaginal bleeding, usually postcoital. Vaginal discomfort, malodorous discharge, and dysuria are not uncommon.

The patient in the above case is demonstrating signs and symptoms of emphysema. Smoking is a leading cause of centrilobular emphysema, and longer exposure to smoke increases the risk of developing the disease. Patients suffering from emphysema are typically thin and often have a pink complexion ("pink puffers"), as compared to those with chronic bronchitis who tend to be somewhat volume overloaded and can be cyanotic appearing ("blue bloaters"). The reason for these phenotypic differences lies in the underlying physiology. Chronic bronchitis leads to increased mucus production and airway obstruction, but alveolar function is preserved. This leads to ventilation/perfusion (V/Q) mismatch and early alveolar hypoxia. If this is diffuse, it results in hypoxemia. Diffuse alveolar hypoxia often results in pulmonary hypertension and reflex fluid retention due to cor pulmonale leading to edema and "bloating." Emphysema results in alveolar destruction with loss of elasticity and recoil, so there is generally matched perfusion and ventilation deficits, which prevents early hypoxemia and cor pulmonale (these often result later in the disease). Increased respiratory effort to overcome the loss of elastic recoil leads to weight loss through increased respiratory effort. In both patients, hypoxemia results in polycythemia. In the setting of V/Q mismatch, this leads to cyanosis (chronic bronchitis). In the setting of emphysema without V/Q mismatch, this leads to a more rosy complexion until later stages of the disease result in more hypoxemia. Patients with emphysema are at risk for frequent exacerbations, which often require hospitalization. Both of these diseases are included under the clinical diagnosis of chronic obstructive pulmonary disease. Treatment is supportive, including the use of inhaled corticosteroids, anticholinergic drugs, and albuterol. Supplemental oxygen is the only medication found to prolong survival. The lungs are autonomically innervated by T2-T7 in patients with chronic lung conditions; expect chronic somatic dysfunction at this level.

true Bottom Line: The classic description of a patient with emphysema is a thin patient with a pink complexion, or a "pink puffer." This is in contrast to the classic chronic bronchitis patient, who is often edematous and cyanotic appearing, or a "blue bloater."COMBANK Insight : You can pretty much guarantee that you are going to see ALL of the above answer choices in different scenarios on your exam day. We cannot emphasize enough how important it is that you are able to diagnose, work up, and treat these lung conditions.

he evolution of stroke is defined by the time course after the initial hemorrhagic, thrombotic or embolic event. The computed tomography (CT) findings in hyperacute ischemic stroke within the initial minutes to hours are typically negative. The purpose of obtaining a CT scan is to determine if the stroke is hemorrhagic or ischemic in etiology. Subtle signs, such as the "dense artery sign" or the "insular ribbon sign," may be seen if the patient is scanned within hours from the onset of their symptoms. As time goes on, the ischemic area will become more defined within the vascular territory involved, which appears hypodense, or lucent, on CT imaging. As the ischemia continues to evolve, encephalomalacia ensues and eventually the brain tissue becomes absorbed and the area previously occupied by brain parenchyma fills with cerebrospinal fluid. Often, while the patient is being treated, serial CT exams of the brain are obtained to be sure there is not hemorrhagic conversion or additional areas of infarct that was not previously recognized. Clinical symptoms are consistent throughout the time course of the stroke consistent with the vascular territory involved. The included CT in the exhibit displays a right middle cerebral artery evolving infarction with fine definition of normal brain against dying neuronal cortex. Subtle signs of mass effect are also noted, with sulcal effacement and compression of the right lateral ventricle. Clinical findings would be expected to involve the left side of the body.

true Bottom Line: The initial imaging for a patient in which acute or subacute stroke is suspected is a non-contrast CT. This will determine if there is a hemorrhagic stroke or subtle signs of ischemia. Here is a breakdown of what to look for on CT when an ischemic stroke is suspected: Early (1-3 hours) (also known as hyperacute phase): Within the first few hours a number of signs are visible depending on the site of occlusion and the presence of collateral flow. Early features include the loss of grey-white matter differentiation, and hypoattenuation of deep nuclei such as the lentiform nucleus. These changes seen as early as 1 hour after occlusion and become visible in 75% of patients at 3 hours. Next, cortical hypodensity with associated parenchymal swelling with resultant gyral effacement becomes visible.First week: With time the hypo-attenuation and swelling become more marked resulting in significant mass effect. This is a major cause of secondary damage in large infarcts. Second to third week: As time goes on the swelling starts to subside and small amounts of cortical petechial hemorrhages results in elevation of the attenuation of the cortex. This is known as the CT fogging phenomenon. Imaging a stroke at this time can be misleading as the affected cortex will appear near normal. Months: The residual swelling passes, and gliosis sets in eventually appearing as a region of low density with negative mass effect. Cortical mineralization can also sometimes be seen appearing hyperdense.

Tracheoesophageal fistula (TEF) is a congenital or acquired communication between the trachea and esophagus, often leading to severe or even fatal pulmonary complications. Typically, diagnosis is made immediately following birth or during infancy. The typical presentation includes excessive oral secretions, inability to feed, respiratory distress and gagging with meals. Esophageal atresia with distal TEF accounts for the majority of cases (80%).

true Bottom Line: Tracheoesophageal fistula (TEF) is a congenital or acquired communication between the trachea and esophagus. Pyloric stenosis is caused by hypertrophy of the gastric pylorus with resultant mechanical obstruction. Symptoms classically begin around one month of age. Emesis is classically non-billious as the obstruction is proximal to the small intestine. An "olive-like" mass is often described in the right upper quadrant of the abdomen although this finding is not sensitive or specific. Emesis is often forceful and the infant appears hungry and well shortly after. Diagnosis is established by abdominal ultrasound. Treatment is by surgical pyloromyotomy. Tracheoesophageal fistula (TEF) is a congenital or acquired communication between the trachea and esophagus, often leading to severe or even fatal pulmonary complications. Most of the time, diagnosis is made immediately following birth or during infancy. The typical presentation includes excessive oral secretions, inability to feed, respiratory distress and gagging with meals. Esophageal atresia with distal TEF accounts for the majority of cases (80%). Summitavely this is an anatomical blind distal pouch of the esophagus with a communication between the trachea and proximal stomach. Food, oral secretions, and water are regurgitated while gastric secretions are aspirated due direct communication between trachea and stomach. Treatment is primary surgical closure of the fistula.TEF may occur as an isolated finding or may be associated with syndromic diseases. CHARGE association does not contain TEF but is often tested as a confounding answer choice. Therefore it is listed in the provided table for completeness.

Patients with cardiac tamponade present with tachypnea, tachycardia, hypotension, muffled heart sounds, jugular venous distention, and pulsus paradoxus. Cardiomegaly is typically seen on x-ray of the chest. Patients with cardiac tamponade require urgent pericardiocentesis.

true Cardiac tamponade occurs when a large pericardial effusion compresses the heart and greatly decreases cardiac output by limiting stroke volume. One of the causes of cardiac tamponade is blunt trauma of the chest. Patients with this diagnosis present with tachypnea, tachycardia, pulsus paradoxus (drop in systolic blood pressure greater than 10 mmHg with inspiration), and jugular venous distention. Beck's triad (hypotension, distant heart sounds, and distended neck veins) is associated with cardiac tamponade. Typically, cardiac enlargement can be seen on chest x-ray, depending on size, and echocardiogram is diagnostic and also provides further insight into cardiac function.

Cirrhosis represents a late stage of progressive hepatic fibrosis characterized by distortion of the hepatic architecture and the formation of regenerative nodules. Many of the complications of cirrhosis are the result of portal hypertension (increased pressure within the portal venous system). Besides varices, other major complications of cirrhosis include ascites, spontaneous bacterial peritonitis, hepatic encephalopathy, hepatocellular carcinoma, hepatorenal syndrome, and hepatopulmonary syndrome. In the setting of upper GI bleeding, the most concerning acute complications of cirrhosis include the development of spontaneous bacterial peritonitis (SBP) due to disrupted mucosal barriers and hepatic encephalopathy. Both can portend a poor prognosis. The development of hypotension and SBP can lead to the development of hepatorenal syndrome and eventual death.

true Cirrhosis represents a late stage of progressive hepatic fibrosis characterized by distortion of the hepatic architecture and the formation of regenerative nodules. Many of the complications of cirrhosis are the result of portal hypertension (increased pressure within the portal venous system). Besides varices, other major complications of cirrhosis include ascites, spontaneous bacterial peritonitis, hepatic encephalopathy, hepatocellular carcinoma, hepatorenal syndrome, and hepatopulmonary syndrome. In the setting of upper GI bleeding, the most concerning acute complications of cirrhosis include the development of spontaneous bacterial peritonitis (SBP) due to disrupted mucosal barriers and hepatic encephalopathy. Both can portend a poor prognosis. The development of hypotension and SBP can lead to the development of hepatorenal syndrome and eventual death. Hepatic encephalopathy: Hepatic encephalopathy describes the spectrum of potentially reversible neuropsychiatric abnormalities seen in patients with liver dysfunction. Several precipitating factors for hepatic encephalopathy include infection, bleeding, constipation, dehydration. This is often treated with lactulose and/or the antibiotic rifaximin. Ascites: Ascites is the accumulation of fluid within the peritoneal cavity. It is the most common complication of cirrhosis. The first step leading to fluid retention and ultimately ascites in patients with cirrhosis is the development of portal hypertension. Spontaneous Bacterial Peritonitis (SBP): SBP is an infection of preexisting ascitic fluid without evidence for an intra-abdominal secondary source, such as a perforated viscus. SBP is almost always seen in the setting of end-stage liver disease. Clinical manifestations of SBP include fever, abdominal pain, abdominal tenderness, and altered mental status. SBP can predispose patients to the development of hepatorenal syndrome.

Twin-to-twin transfusion syndrome occurs in monozygotic monochorionic twins and is the result of intrauterine blood transfusion from one twin to another. The donor twin will be small for gestational age; will develop hypovolemia, anemia, and oligohydramnios; and will be oliguric. The recipient twin will be large for gestational age, plethoric, and ruddy and have hypervolemia, polyhydramnios, jaundice, hypertension, and congestive heart failure. This is due to hypoperfusion of the donor twin and hyperperfusion of the recipient twin. Hemoglobin differences are typically greater than 5 g/dL. Hydrops fetalis can present in both twins. Treatment is a reduction amniocentesis.

true Congestive heart failure will be seen in the recipient twin. Hypervolemia will be seen in the recipient twin. The recipient twin will be large for gestational age. Polyhydramnios will be seen in the recipient twin.

This patient has experienced an arachnid bite consistent with the bite of a black widow spider. One of the most crucial steps in treating spider bites is identifying the offending spider. The black widow (Latrodectus spp.) lives in the trash, closets, attics, woodpiles, garages, and other dark places. The black widow is a shiny black spider with a large round tail segment. Red to orange-colored markings, usually in the shape of an hourglass, are found on the underside of the belly. A black widow spider bite looks like a pale area surrounded by a red ring, grossly resembling a target. The signs and symptoms may differ depending on whether the spider has neurotoxic or cytotoxic venom. The neurotoxic venom causes the release of acetylcholine, which results in muscle spasm and pain, abdominal cramping or rigidity, nausea, vomiting, salivation, and lacrimation. Symptoms are usually present 1-3 hours after the bite. Cytotoxic venom affects cellular tissue, and changes are usually limited to the area of the bite. The initial bite is initially painless, but symptoms develop about 2-8 hours later as the area becomes swollen and painful. Eventually, a blister may form over a necrotic lesion, which then sloughs to create an ulcerated wound (up to 10 cm in diameter). The ulcer will heal over months and leave behind a scar. In extreme cases, skin grafts may be necessary. Systemic conditions may also occur, eg, thrombocytopenia, disseminated intravascular coagulation, or renal failure. In mild cases, treatment is usually supportive, with acetaminophen, warm compresses, and elevation of affected extremities.

true Conservative management is indicated for uncomplicated black widow spider bites. Do not forget to include local wound care and tetanus prophylaxis in these patients.

Bottom Line: Guidelines for weight gain according to BMI are divided into four categories: underweight (BMI < 19.8), acceptable (BMI 19.8-26.0), overweight (BMI 26.1-29.0) and severely overweight (BMI > 29.0). The recommended weight gain in pregnancy for underweight patients is greater than 35 pounds, 25-35 pounds for patients in the acceptable category, 15-25 pounds for overweight patients and 11-20 pounds for severely overweight patients.

true Current guidelines for changes in weight during the course of pregnancy are based on pre-pregnancy body mass index. An increase of 100-300 kcal/day is recommended during the course of pregnancy while an increase of 500 kcal/day is recommended during breast feeding in the postpartum period. Excessive weight gain is greater than 1.5 kg/month while inadequate weight gain is less than 1 kg/month. Guidelines for weight gain according to BMI are divided into four categories: underweight (BMI < 19.8), acceptable (BMI 19.8-26.0), overweight (BMI 26.1-29.0) and severely overweight (BMI > 29.0). The recommended weight gain for underweight patients is greater than 35 pounds, 25-35 pounds for patients in the acceptable category, 15-25 pounds for overweight patients and 11-20 pounds for severely overweight patients.

Chediak-Higashi syndrome presents with a combination of findings including oculocutaneous albinism, silver hair and recurrent infections.

true Chédiak-Higashi syndrome (CHS) is a rare childhood autosomal recessive disorder that affects multiple systems of the body. Patients with CHS exhibit hypopigmentation of the skin, eyes, and hair; prolonged bleeding times; easy bruisability; recurrent infections; abnormal natural killer cell function; and peripheral neuropathy. Morbidity results from patients succumbing to frequent bacterial infections or to an accelerated-phase lymphoproliferation into the major organs of the body. Most patients who do not undergo bone marrow transplantation die of a lymphoproliferative syndrome, although some patients with CHS have a relatively milder clinical course of the disease.

Bottom Line: A woman with a family history of breast cancer should initiate annual screening 10 years before the first-degree relative's age at diagnosis.COMBANK Insight : Guidelines for cancer screening are always tested on COMLEX exams. Because recommendations differ between different cancer types, it is important to thoroughly review this topic prior to your exam date. Breast and colon cancer are by far the most frequently tested cancer types; however, be sure to review guidelines for all major cancers.

true Current recommendations for breast cancer screening are based on the natural history of tumorigenesis. The United States Preventative Services Task Force (USPSTF) recommends biennial screening for breast cancer beginning at age 50. The American Cancer Society, however, recommends annual screening for breast cancer beginning at age 40. To address this on the COMLEX, be aware that the COMLEX will not likely give both options (beginning at age 40, beginning at age 50) as answer choices. Be familiar with both screening recommendations.

Bottom Line: Pseudomonas aeruginosa is 1 of the 2 most common causative agents of pneumonia in patients with cystic fibrosis. After ages 25-34, P. aeruginosa is the most prevalent bacteria isolated from the sputum. Staphylococcus aureus is the most common organism isolated in the first 25-34 years of life.COMBANK Insight : Pneumonia is a must-know topic for Level 3. You need to be able to recognize the most likely pathogen given a certain clinical situation, including cystic fibrosis.

true Cystic fibrosis (CF) is the most common autosomal genetic disease in North America, affecting 1:2000 white individuals. After 25-34 years of age, Pseudomonas aeruginosa is the most prevalent bacteria isolated from the sputum. The most common organism to cause respiratory exacerbations in patients with cystic fibrosis varies by patient age and registry. In general, the following trends are observed: Staphylococcus aureus is the most common organism isolated until 25- 34 years of age and then Pseudomonas becomes more common H influenza is the second most common organism in children under 10 Overall (all ages):Staphlococcus aureus is found in 70.7% of respiratory culturesPseudomonas aeruginosa is found in 45.7% of respiratory culturesStenotrophomonas maltophilia is found in 12.9% of respiratory culturesBurkholderia cepacia complex is found in 2.5% of respiratory cultures Rib dysfunctions are a type of somatic dysfunction in which movement or the position of a rib is altered or disrupted. This can be seen with a single rib, or it can be a group dysfunction. In a group dysfunction, there is usually 1 rib that is responsible for causing the dysfunction, referred to as the "key rib." This particular case is describing an exhalation dysfunction. In a group exhalation dysfunction, the dysfunctional ribs will move caudad during exhalation; however, the dysfunctional ribs will not move cephalad during inhalation. The rib will appear to be "stuck down." In ribs with bucket handle motion (ribs 6-10), there will be lateral narrowing of intercostal space below the dysfunctional rib in an exhalation dysfunction. Lastly, in a group exhalation dysfunction, the key rib is the uppermost rib (in this case, rib 6 on the right).

Bottom Line: Evidence of renal disease is a strong predictor of retinopathy in insulin-dependent diabetics.COMBANK Insight : Diabetes mellitus is always hit hard on COMLEX exams and represents a large percentage of the endocrinology section, along with hypo-/hyperthyroidism. Questions regarding diabetes are rarely straightforward and are often based on current management guidelines. For example, you may be asked to select the most "cost-effective" test for diagnosis, or you may be asked questions related to screening guidelines, as represented in the case above. Make sure you are familiar with these topics and can manage the complications seen in diabetic patients.

true Diabetic retinopathy is one of many complications associated with poorly controlled insulin-dependent diabetes mellitus. Renal disease, marked by proteinuria and elevated blood urea nitrogen/creatinine levels, is a strong predictor of diabetic retinopathy. Both retinopathy and nephropathy occur secondary to diabetes-related microangiopathies and reflect on one another accordingly. Treatment of nephropathy may have a beneficial effect on the progression of retinopathy and neovascular glaucoma.Answer A: Diabetic retinopathy has been shown to actually worsen during pregnancy. Pregnant patients with diabetes should undergo fundoscopic examination during each trimester of pregnancy.Answer B: Dot and blot hemorrhages appear to be hypofluorescent, not hyperfluorescent, on fluorescein angiography.Answer C: Hypertension strongly correlates with retinopathy and may lead to hypertensive retinal vascular changes, which add to preexisting retinopathy and even further compromise retinal blood flow.Answer E: Patients diagnosed with type I diabetes should undergo annual ophthalmic screening following diagnosis.

Bottom Line: If there is concern for ectopic pregnancy, a HCG quant and pelvic ultrasound should be ordered to evaluate for intrauterine or ductal pregnancy even if a repeat point of care pregnancy testing is negative. If you remember, urine testing may be falsely negative early in a woman's pregnancy if HCG levels are not yet high enough to be detectable in urine.COMBANK Insight : In the ED, this patient would likely have a urine point-of-care pregnancy test done before the BHCG, however, that was not an option in the question answer choices. Just because an answer is not present that you believe should be, should not deter you from picking other correct choices. Sometimes, all of the correct answers will not be options.

true Ectopic pregnancy, also known as a tubal or extrauterine pregnancy, develops when the embryo implants into a structure outside of the uterus. This is most commonly the fallopian tube, however, the embryo could potentially implant within the peritoneal cavity as well. Signs and symptoms classically include abdominal pain and vaginal bleeding, although less than 50% of women have both of these symptoms. The pain may be described as sharp, dull, or crampy. Pain may also spread to the shoulder if bleeding into the abdomen has occurred. Some women may mistake vaginal bleeding and abdominal pain for their normal menstrual period, especially if they have irregular periods or do not routinely track their cycle. If there is rupture of the fallopian tube with damage to the accompanying arterial supply to the ovary, there can be catastrophic bleeding, leading to shock and death. Ectopic pregnancy should be considered in the differential diagnosis of every woman presenting with abdominal pain and vaginal bleeding who is of reproductive age.Once pregnancy has been established by HCG testing, then intrauterine pregnancy should be confirmed with pelvic ultrasound using transvaginal imaging if needed. If intrauterine pregnancy cannot be confirmed then serial HCG measurements can be obtained to ensure that the pregnancy is not within the fallopian tube. An HCG quant should be obtained in any patient suspected of having an ectopic pregnancy as the value can help guide further therapy if the embryo can not be visualized on ultrasound. The BHCG should double every 48 to 72 hours, however, in the setting of ectopic pregnancy, the limited space for embryonic growth retards the normal increase in BHCG, leading to lower than expected values.This patient has a history of chlamydial infection and abdominal pain with vaginal bleeding. Pelvic inflammatory disease should be a consideration and would warrant treatment, especially in a pregnant patient. During the vaginal exam cervical discharge should be sent for chlamydia and gonorrhea and she should be treated if positive.Any pregnant patient presenting with vaginal bleeding should undergo blood typing. This is not only to ensure that blood is available for transfusion if necessary, but for evaluation of Rh antigen positivity. If the pregnant mother is Rh negative and is exposed to Rh positive blood, she will develop antibodies against the Rh antigen and on future pregnancies, those Ig antibodies can cross the placenta and cause widespread destruction of fetal red blood cells and the development of hydrops fetalis or hemolytic disease of the newborn. To prevent this, Rh negative mothers should be given a dose of Rhogam or Rh immune globulin which will block the antigen from being recognized by the immune system. This will prevent the formation of antibodies.

CT scan myelography may be preferred by surgeons for evaluating patients before reoperation or for evaluating patients who have severely spondylotic changes. This is because CT scan myelography can delineate bony structures better than MRI.

true Electromyography is rarely helpful in the diagnosis or management of lumbar disc disease. Occasionally, a diabetic patient can be identified as having a polyradiculopathy or plexopathy. On this basis, some surgeons proceed to surgery with more caution.

Placement of a copper intrauterine device is the most effective means of postcoital contraception, and can be utilized up to 7 days following an unprotected sexual encounter for pregnancy prevention.

true Emergency contraception can be utilized following unprotected sexual intercourse to prevent unwanted pregnancy. There are various methods of postcoital contraception, including the administration of emergency contraceptive pills (ECPs), the minipill emergency contraception method (MECM), and finally, the use of a copper intrauterine device (IUD).Placement of a copper intrauterine device is the most effective means of postcoital contraception and can be inserted within 7 days following an unprotected sexual encounter for pregnancy prevention. It is also beneficial as a contraceptive device. Depending on the device, placement can last for 10 years. The ECP mode involves oral therapy with 0.5 mg of levonorgestrel and 100 mcg of ethinyl estradiol taken on 2 occasions for a total of 4 pills. This method has been shown to have an effectiveness of 50% to 90%. The MECM is utilized by treating the patient with a 2-time dose of levonorgestrel. The placement of a copper IUD can occur up to 7 days following the encounter and is significantly more effective than either the ECP or MECP regimens. IUD placement reduces the risk of pregnancy by more than 99%, making it the most effective means of postcoital contraception.

Bottom Line: Endometrial cancer is the most common gynecologic cancer in women older than age 45. The correct management for this patient is total abdominal hysterectomy and bilateral adnexectomy.COMBANK Insight : Because approximately 75% of women with endometrial cancer are postmenopausal, the most common symptom is postmenopausal bleeding.

true Endometrial cancer is the third most common cause of death from women's cancers, behind ovarian and cervical cancer. The first sign is most often vaginal bleeding not associated with a menstrual period. Other symptoms include pain with urination or sexual intercourse or pelvic pain. Endometrial cancer occurs most commonly after menopause. Approximately 40% of cases are related to obesity. Endometrial cancer is also associated with excessive estrogen exposure, high blood pressure, and diabetes. Whereas taking estrogen alone increases the risk of endometrial cancer, taking both estrogen and progesterone in combination, as in most birth control pills, decreases the risk. The most frequent type of endometrial cancer is endometrioid carcinoma, which accounts for more than 80% of cases. Endometrial cancer is commonly diagnosed by endometrial biopsy or by taking samples during a dilation and curettage. A pap smear is not typically sufficient to show endometrial cancer. Regular screening in those at normal risk is not called for. If the disease is diagnosed at an early stage, the outcome is favorable, and the overall 5-year survival rate in the United States is greater than 80%. In 2012, endometrial cancers occurred in 320,000 women and caused 76,000 deaths.Endometrial carcinoma is surgically staged using the International Federation of Gynecology and Obstetrics (FIGO) cancer staging system. The 2009 FIGO staging system is as follows:Stage IA Tumor is confined to the uterus with less than half myometrial invasion IB Tumor is confined to the uterus with more than half myometrial invasionStage II Tumor involves the uterus and the cervical stromaStage IIIA Tumor invades serosa or adnexa IIIB Vaginal and/or parametrial involvement IIIC1 Pelvic lymph node involvement IIIC2 Para-aortic lymph node involvement, with or without pelvic node involvementStage IVA Tumor invades bladder mucosa and/or bowel mucosa IVB Distant metastases including abdominal metastases and/or inguinal lymph nodesPatients suspected of having endometrial cancer should have pathologic confirmation of disease by either endometrial biopsy or dilation and curettage. The staging of endometrial cancer is surgically based. Preoperative evaluation should include physical examination and chest radiography. The uterine size, potential extrauterine tumor involvement, and presence of comorbidities should be assessed on examination. Other testing may include Pap smear, transvaginal ultrasonography, cancer antigen-125 level, or magnetic resonance imaging if extrauterine metastases are suspected. From a primary care perspective, the preoperative evaluation should also focus on optimizing medical comorbidities that could complicate the course of treatment.In the absence of obvious extrauterine metastases, staging and initial treatment are accomplished with total hysterectomy, bilateral salpingo-oophorectomy, and peritoneal washings. Based on risk factors such as extent of myometrial invasion and tumor grade, pelvic and para-aortic lymph node dissection should be performed as a prognostic indicator and a treatment strategy. With more advanced stages of disease, tumor debulking is indicated to improve treatment outcomes. Radiation therapy via external-beam radiotherapy or brachytherapy is an effective treatment for endometrial cancer. In stage I disease, the use of radiation therapy is beneficial for patient subgroups determined by age, tumor grade, depth of myometrial invasion, and lymphovascular space involvement. In more advanced disease, radiation therapy is useful in women with lymph node involvement and regional spread. It also effectively controls local recurrence of disease. Systemic therapy with high-dose progestins or chemotherapy may benefit patients with metastatic disease. Progestins alone or in combination with tamoxifen have shown increased progression-free and overall survival rates. Doxorubicin (Adriamycin) and paclitaxel (Taxol), in addition to the use of a platinum-based agent, have also demonstrated improved survival in women with advanced or recurrent disease.

Experts now use a reference level of 5 μg/dL to identify children with blood lead levels that are much higher than the levels of most children. This new level is based on the US population of children age 1 to 5 years who are in the highest 2.5% of children when tested for lead in their blood.

true Experts now use a reference level of 5 µg/dL to identify children with blood lead levels that are much higher than the levels of most other children. This new level is based on the US population of children age 1 to 5 years who are in the highest 2.5% of children when tested for lead in their blood. This reference value is based on the 97.5th percentile of the National Health and Nutrition Examination Survey's (NHANES) blood lead distribution in children. Chelation therapy should be considered when a child has a blood lead test result greater than or equal to 45 µg/dL. Chelation agents contain sulfhydryl groups that bind or chelate lead, and the resulting complex is excreted either renally or hepatically. The chelation agents succimer and penicillamine are given orally, whereas dimercaprol and edetate (EDTA) calcium disodium (CaNa2 EDTA) are administered parenterally. These agents reduce body stores of lead. Reducing blood lead levels also may mobilize skeletal stores of lead. Therefore, caution must be exercised in using chelation agents, both because of their adverse effects and because of their ability to mobilize lead.No pathognomonic symptoms exist. When symptoms do occur, they are typically nonspecific. Consider lead poisoning whenever a small child presents with peculiar symptoms that do not match any particular disease entity. Common nonspecific symptoms include temperamental lability, irritability, behavioral changes, hyperactivity or decreased activity, loss of developmental milestones, and/or language delay. More significant exposure to lead may cause abdominal pain, loss of appetite, vomiting, constipation, headache, ataxia, somnolence, lethargy, seizures, stupor, and/or coma.

Bottom Line: Collect fetal fibronectin first in patients with signs or symptoms of preterm labor between 22 and 35 weeks of gestation.

true Fetal fibronectin is an adhesive protein that is present at the maternal-fetal interface. Fetal fibronectin should not be found in vaginal sections between 22 and 35 weeks of gestation. Disruption of the maternal-fetal interface causes the release of fetal fibronectin into the vaginal secretions. This is an indicator of preterm birth risk. The fetal fibronectin test is collected with the aid of a speculum. Collection is contraindicated outside of those gestational ages and in the presence of rupture of membranes, active vaginal bleeding, or anything in the vagina in the past 24 hours, such as intercourse. With a negative fetal fibronectin result, the physician can be 99% sure that the patient will not go into preterm labor in the next 2 weeks.

The radial styloid is usually tender with palpation, along with a positive Finkelstein test, confirming diagnosis of De Quervain tendinopathy. Finkelstein test draws the tendons of the first dorsal compartment distally, which in turn causes a sharp pain when tendon entrapment has occurred. This test is conducted by asking the patient to hold their thumb inside their palm. Next, the physician ulnar deviates the hand. Pain over the extensor pollicis brevis and abductor pollicis longus tendons is a positive test.

true Finkelstein test is flexion of the thumb across the palms with ulnar deviation, which will elicit a sharp pain in the first dorsal compartment. A positive test is indicative of De Quervain tenosynovitis. Bottom Line: First-line treatment for De Quervain tendinopathy is splinting (thumb spica splint). The above findings represent a typical case of De Quervain tendinopathy. Diagnosis is made by history and physical exam. Classically, the patient will have tenderness over the radial aspect of the forearm. Finkelstein test may be positive. Prognosis is favorable and conservative treatment is often successful. The first step in management is a trial of splinting (thumb spica splint). If this is unsuccessful, corticosteroid injection may be attempted. If symptoms are severe and persistent, a surgical approach is often recommended.

Bottom Line: Bulimia nervosa is associated with volume depletion from vomiting/laxative abuse, which can be intensified by diuretic use or fasting, which causes secondary hyperaldosteronism, renal potassium loss and hypokalemiaCOMBANK Insight : It is common for a psychiatric question to include medical complications associated with the psychiatric disorder. If you can remember some basic physiology you should be able to reach the correct answer by process of elimination.

true Fluid loss and volume depletion from vomiting/laxative abuse, which can be intensified by diuretic use or fasting, causes secondary hyperaldosteronism, renal potassium loss, and hypokalemia. Hypokalemia, in turn, can present with palpitations, weakness, paralysis, constipation, nausea, and vomiting, as well as abdominal cramping. Physical findings include signs of ileus and hypotension. Hypophosphatemia and hypomagnesemia can occur from laxative abuse; low serum phosphates levels have also been noted in those who vomit 3 or more times per day. Loss of hydrogen ions with vomiting increases bicarbonate levels, resulting in metabolic alkalosis. Intestinal loss of bicarbonate, chloride, and potassium with laxative abuse can cause metabolic acidosis.

Bottom Line: With the exception of unusually high low-density lipoprotein (LDL) levels (>190 mg/dL), it is no longer recommended to use target values when evaluating the need for statin therapy. Rather, 4 specific groups have been identified that benefit from statin therapy, including those with: (1) atherosclerotic cardiovascular disease (ASCVD); (2) those with LDL levels >190 mg/dL; (3) diabetics between age 40 and 75 years with LDL levels >70 mg/dL; and (4) those without ASCVD or diabetes but with an estimated 10-year ASCVD risk of 7.5% or higher.

true Four major patient groups who should be treated with statins were identified that benefit from treatment with statins:1. Individuals with clinical atherosclerotic cardiovascular disease (ASCVD)*2. Individuals with LDL cholesterol levels >190 mg/dL (such as those with familial hypercholesterolemia) 3. Individuals with diabetes aged 40 to 75 years old AND LDL cholesterol levels between 70 and 189 mg/dL4. Individuals without evidence of cardiovascular disease or diabetes but who have LDL cholesterol levels between 70 and 189 mg/dL and a 10-year risk of ASCVD >7.5%* This includes patients with acute coronary syndromes such as a history of unstable angina or myocardial infarction; history of stroke or transient ischemic attack; or peripheral artery disease.

Patients suffering from Crohn disease often present with inflammatory changes in the terminal ileum, identified by abdominal CT.

true Low-grade fever, prolonged diarrhea with abdominal pain, weight loss, and generalized fatigability are usually reported. The patient may develop crampy or steady right lower quadrant or periumbilical pain. The pain precedes, and may be partially relieved, by defecation. Diarrhea is usually not grossly bloody and is often intermittent. If the colon is involved, patients may report diffuse abdominal pain accompanied by mucus, blood, and pus in the stool. Inflammatory changes of the terminal ileum identified by abdominal CT is the most common initial finding in patients with newly diagnosed Crohn disease. Although cecal involvement may also be noted, it is the terminal ileum that is most often affected. Intra-abdominal abscesses and fistulas may also be noted. note: Because the patient has been experiencing symptoms for several months, the likelihood of normal findings by CT is minimal.

Bottom Line: Dry gangrene is secondary to lack of blood supply to the affected limb usually from atherosclerosis. Clinically, dry gangrene usually presents as a cold, bluish-black, dry, and shriveled toe. Referral to a vascular surgeon to determine if the patient is a candidate for revascularization or to determine if amputation is necessary is the correct treatment.

true Gangrene is a serious medical condition that occurs when there is tissue necrosis, or tissue death, in a considerable mass of body tissue. Dry gangrene is the result of insufficient blood supply to tissue most likely secondary to atherosclerosis. This may occur after injury or infection or in patients with chronic medical conditions affecting the circulation, such as diabetes mellitus and long-term smoking, as in this case. There are different types of gangrene, including dry gangrene, wet gangrene, gas gangrene, internal gangrene, and necrotizing fasciitis. Restoring the blood supply to the ischemic tissue is vital. Management often involves a referral to a vascular surgeon for possible revascularization. Other treatment options include debridement, antibiotics, vascular surgery, maggot therapy, or hyperbaric oxygen therapy. If the blood supply cannot be restored, then the toe must be amputated.

Bottom Line: The middle third of the hyoid bone is almost always removed when excising a thyroglossal duct cyst.COMBANK Insight : You may have oddly specific questions on your test day. Answer these the best you can and move on. The total number should be relatively few compared to the overall exam.

true Generally, the middle third of the hyoid bone must be removed in order to fully excise the sinus tract. Sometimes, there can be communication between the cyst and the bone; other times they remain in very close proximity. There are new surgical procedures being pioneered which preserve the hyoid bone, but are not yet routinely performed and their clinical impact is questionable. Thyroglossal cysts develop at birth. The thyroglossal tract arises from the foramen cecum at the junction of the anterior two-thirds and posterior one-third of the tongue. Any part of the tract can persist, causing a sinus, fistula or cyst. Most fistulae are acquired following rupture or incision of the infected thyroglossal cyst. Imaging in children is required to establish a diagnosis and ultrasound is the preferred modality due to lack of radiation and non-invasiveness. In adults, there is concern for developing malignancy within the thyroid remnant, and CT of the neck can better reveal the usual calcification that is a sign of papillary carcinoma (the most common cyst malignancy).

A patient with acute upper GI bleed with cirrhosis must get 2 large-bore IVs or a large-bore, single lumen central catheter, IV fluids, blood as needed, a IV proton pump inhibitor drip, IV octreotide drip, IV antibiotics for SBP prophylaxis, and generally will require ICU admission. An EGD should be performed within 24 hours of admission, but ideally as soon as possible, once the patient is hemodynamically stable.

true Given this patient's hypotension and tachycardia she is currently hemodynamically unstable. The first step should be to obtain large-bore IV access or a large-bore, single-lumen central catheter for fluid resuscitation and blood products. Obviously, peripheral IV access is preferred. Patients with active bleeding and hypovolemia may require red blood cell transfusion despite an apparently normal hemoglobin, particularly if the patient remains hemodynamically unstable despite appropriate fluid resuscitation. Given this patient is hemodynamically unstable with active variceal bleeding, she would likely require ICU admission for close monitoring and stabilization. Patients admitted to the hospital with acute upper GI bleeding are typically treated with an IV proton pump inhibitor (PPI) therapy due to concern for underlying peptic ulcer disease. High dose antisecretory therapy with an intravenous infusion of a PPI significantly reduces the rate of rebleeding compared with standard treatment in patients with bleeding ulcers. Additionally, she should receive IV octreotide, a somatostatin analog. It inhibits the release of vasodilator hormones such as glucagon, indirectly causing splanchnic vasoconstriction and decreased portal inflow which can help mitigate variceal bleeding. Multiple trials evaluating the effectiveness of prophylactic antibiotics in cirrhotic patients hospitalized for GI bleeding suggest an overall reduction in infectious complications and possibly decreased mortality. Antibiotics may also reduce the risk of recurrent bleeding in hospitalized patients who bled from esophageal varices. Finally, the patient will need an upper endoscopic procedure to evaluate the cause of bleed and possible treatment options such as banding of varices, sclerotherapy, or clipping of visible vessels. Upper endoscopy should be performed after fluid resuscitation and within 12 hours of hospital admission. All patients with cirrhosis should have a paracentesis if the presence of ascites is confirmed to rule out SBP. Those patients found to have SBP should receive hepatorenal syndrome prophylaxis with albumin on days 1 (1.5g/kg) and 3 (1g/kg) of admission.

Ulnar nerve entrapment at the wrist (Guyon canal) results in hypothenar atrophy and difficulty with finger adduction/abduction. If the entrapment occurs at the level of the elbow (cubital tunnel), there will also be impaired flexion of the 4th and 5th digits and paresthesia.

true Guyon canal syndrome occurs when there is entrapment of the ulnar nerve as it passes through the wrist. Anatomically, the ulnar nerve is entrapped as it passes through the tunnel formed by the pisiform and hamate bones and the pisohamate ligament at the level of the wrist. This can lead to atrophy of the hypothenar eminence and impairs both adduction and abduction all fingers. Sensory findings are often absent in ulnar nerve entrapment at Guyon canal, as the sensory innervation tends to branch out from the ulnar nerve prior to entering Guyon canal (for example, the dorsal ulnar cutaneous nerve branches off about 5 cm proximal to the wrist); however, due to anatomic variance, sometimes paresthesias to the palmar surface of digits 4 and 5 may be present.

Clopidogrel prevents platelet aggregation reducing the formation of arterial clots. It is appropriate for peripheral artery disease.

true Heparin is appropriate management for a deep vein thrombosis. Topical steroids are the treatment of choice for inflammatory conditions such as atopic dermatitis. They should generally be avoided in venous stasis ulceration because they may retard healing.

Hyperemesis gravidarum (HG) is a condition that causes frequent vomiting in pregnant women. It is similar to morning sickness, except the symptoms are much more severe. Diagnosis is based on symptoms of severe nausea and vomiting in conjunction with a loss of > 5% of the patient's prepregnancy weight. It usually occurs in the first trimester, and symptoms usually resolve by mid-pregnancy regardless of severity and need for therapy. Pregnant women with severe vomiting should present to the emergency room if they have symptoms of hypovolemia, which include decreased energy, postural dizziness, thirst, tachycardia, or decreased urine volume or frequency. These women should be treated with IV fluids. It is also important to replenish other vitamins and minerals such as thiamine, folic acid, magnesium, calcium, and phosphorus. Antiemetic medications may be used, but the risks of a small increase in congenital anomalies for patients under 10 weeks' gestation must be considered. The first line antiemetic medication in hospitalized patients with HG is ondansetron.Once vomiting is controlled and the patient is sent home, there are a variety of options to manage nausea. These include ginger-containing foods, vitamin B6 (Pyridoxine), and the combination doxylamine-pyridoxine. Doxylamine is an antihistamine that is traditionally used as a sleep aid medication. Ginger has been found to decrease nausea, but it has not been found to reduce vomiting. Pyridoxine has also been found to significantly reduce nausea, but not vomiting. It is often used first line due to its efficacy and minimal side effects. The combination doxylamine-pyridoxine has been found to help with both nausea and vomiting. Other alternative treatments such as acupuncture and hypnosis have also been found to be helpful in some patients.

true Hyperemesis gravidarum is based on the presence of nausea and vomiting, plus loss of > 5% of the patient's prepregnancy weight, dehydration, and electrolyte imbalance.

Flushing is associated with hypermagnesemia, not pallor.

true Hyperkalemia is associated with hypermagnesemia, not hypokalemia. Hypocalcemia is associated with hypermagnesemia, not hypercalcemia. This patient has severe preeclampsia and is given magnesium for seizure prophylaxis, which places her at risk for hypermagnesemia. Neuromuscular toxicity is the most consistently observed complication of hypermagnesemia. Increased magnesium decreases impulse transmission across the neuromuscular junction, resulting in diminished deep tendon reflexes that are usually first noted when the plasma magnesium concentration reaches 4 to 6 mEq/L. Other side effects of magnesium include respiratory paralysis, pulmonary edema, hypocalcemia, hyperkalemia, and flushing. The initial treatment for magnesium toxicity is intravenous calcium gluconate. This patient has symptoms of magnesium toxicity. Magnesium toxicity is related to serum concentration, with a loss of deep tendon reflexes occurring at 9.6 to 12.0 mg/dL, respiratory paralysis at 12.0 to 18.0 mg/dL, and cardiac arrest at 24 to 30 mg/dL. Calcium gluconate is the treatment that should be given to any patient displaying life-threatening symptoms of hypermagnesemia, as described in this patient's case.

Bulimia nervosa is an eating disorder with 5 key characteristics as noted by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).The patient in the above case carries the diagnosis of bulimia nervosa, which is a common eating disorder among teenage girls. The disorder is characterized by binge eating followed by forced emesis, which results in decaying tooth enamel and callus formation over the knuckles. The 5 key characteristics are as follows:1) Recurrent episodes of binge eating. Eating more than the average person in a 2-hour period, accompanied by a sense of loss of control.2) Repetitive inappropriate compensatory behaviors to avoid weight gain such as excessive exercise, fasting, laxative use, and diuretic use.3) This eating behavior occurs at least once a week for a period of 3 months.4) Body shape and weight influence self-evaluation.5) This does not occur specifically with episodes of anorexia nervosa.Among the eating disorders, bulimia nervosa and anorexia nervosa are far more common in young females, whereas binge-eating disorder, the most common eating disorder overall, is more common in adults. In up to 60% of cases, patients with bulimia nervosa report prior histories of anorexia nervosa. In contrast to individuals with uncomplicated binge-eating disorder who tend to be obese, people with bulimia nervosa are more typically of normal weight, although some degree of overlap between nonpurging bulimia nervosa and binge-eating disorder is seen. The natural history of eating disorders is such that individuals may pass through several diagnoses over time, with some meeting criteria for anorexia nervosa, bulimia nervosa, and binge-eating disorder at various points. The development of anorexia nervosa in individuals who initially present with bulimia nervosa is possible, although less common. Compensatory behaviors used by individuals with bulimia nervosa include self-induced vomiting, laxative abuse, excessive exercise generally experienced as being joyless and/or compulsive, episodes of fasting or strict dieting, diuretic abuse, use of appetite suppressants, failure to use insulin in those with type 1 diabetes, and/or the use of medications intended to speed up metabolism (eg, thyroid hormone).

true Hypokalemia, hypochloremia, hyperphosphatemia, and metabolic alkalosis are common, especially in lower-weight bulimics. The severity of hypokalemia and hypochloremia is directly related to the number of purging episodes the patient experiences, especially those involving diuretics, laxatives, and repetitive vomiting. Patients who purge by vomiting may present with metabolic alkalosis (elevated serum bicarbonate levels) due to volume contraction. Measurement of urinary potassium levels may be useful; a value of less than 10 mmol per liter in a "spot" urine specimen usually suggests a gastrointestinal cause of potassium loss. However, patients who primarily abuse laxatives may present with metabolic acidosis (decreased serum bicarbonate levels) due to loss of alkaline fluid from the bowel. This patient has constipation and so this possibility becomes less likely. Patients using more than one purging mechanism may display mixed acid-base findings. These electrolyte imbalances contribute to weakness, fatigue, and, in severe cases, may predispose the patient to cardiac arrhythmias and sudden death.These patient's frequently present with a "Pseudo-Bartter's syndrome", defined as normotensive, hypokalemic alkalosis, is common among patients who vomit or use diuretics excessively. Volume depletion induces hyperaldosteronism Renal loss of hydrogen ions occurs when excess aldosterone increases the activity of a sodium-hydrogen exchange protein in the kidney. This increases the retention of sodium ions while pumping hydrogen ions into the renal tubule. Excess sodium increases extracellular volume and the loss of hydrogen ions creates a metabolic alkalosis

In an older male with decreased urine output, a weak urinary stream, and nocturia, the most likely diagnosis is benign prostatic hypertrophy (BPH). Histologically, BPH is defined as a proliferation of glandular epithelial tissue, smooth muscle, and connective tissue within the prostatic transition zone. The most common physical exam finding for BPH is a non-tender, uniformly enlarged prostate without nodules or other suspicious findings. When taking a history you should include questions regarding symptoms such as frequency, urgency, and nocturia as well as voiding symptoms such a slow or decreased force of urinary stream, straining to void, intermittency, hesitancy, or splitting of the voiding stream as well as post-void dribbling. Symptoms of hematuria, incontinence, or urinary retention should prompt urology referral. BPH only requires therapy if symptoms have a significant impact on a patient's quality of life. Treatments include behavioral therapy, alpha-1-adrenergic antagonists, 5-alpha-reductase inhibitors, anticholinergic agents, and phosphodiesterase-5 inhibitors.

true In a patient with suspected BPH and urinary retention, you would need to evaluate renal function as well as rule out infection and hematuria. Patients with BPH may develop renal insufficiency due to chronic urinary obstruction, therefore assessment of renal function is standard of care in these patients. So, a basic metabolic panel (BMP) and urinalysis should be ordered. Also keep in mind that, of the answer choices, the BMP and urinalysis are the least costly and least invasive, as well as the most readily available test listed.

Tissue plasminogen activator (TPA) is a thrombolytic therapy that is used for patients with PE who are hemodynamically unstable, usually with refractory hypotension. This patient does not have hypotension and should be managed with anticoagulation. TPA is not indicated in this case.

true In patients with significant right heart strain who are otherwise hemodynamically stable, consideration can be made for catheter-directed thrombolysis. This patient does not require that intervention currently. An echocardiogram is indicated in patients with a PE who are hemodynamically unstable or in whom right heart strain is strongly suspected. On the echocardiogram, you can see right ventricular hypokinesis, regional wall motion abnormalities that spare the right ventricular apex known as McConnell's sign, or visualization of clot. In a hemodynamically unstable patient with these signs, systemic thrombolytic therapy can be administered.

Bottom Line: Smokers can decrease their risk of postoperative pulmonary complications to that of nonsmokers if cessation occurs at least 6 to 8 weeks prior to surgery.

true In the United States, nearly 1 in 5 adults abuse tobacco. Nicotine has many physiologic effects, including a dose-related increase in heart rate and systolic and diastolic blood pressure, and increased vascular resistance, especially in coronary and cerebral vessels. Smokers have carbon monoxide levels of 5% to 20% depending upon smoking pattern and, therefore, have significantly decreased oxygen-carrying capacity. Smoking is an independent risk factor for perioperative bronchospasm. Increased sputum production in smokers is associated with increased infective pulmonary complications and a higher rate of intensive care unit admissions with prolonged mechanical ventilation after surgery. Smoking is also an independent predictor for perioperative stroke and renal dysfunction. Perioperative pulmonary complications can be decreased by preoperative smoking cessation, but cessation must be initiated 6 to 8 weeks prior to surgery.

Bottom Line: For a patient with hypertension who is taking a diuretic or angiotensin-converting enzyme inhibitor (ACEI)/angiotensin receptor blocker (ARB), a basic metabolic profile, including creatinine and potassium, should be checked to ensure that there are no signs of worsening renal function (which could impair function of the medication) or electrolyte disturbances, which could lead to an arrhythmia.

true It is appropriate to screen this patient for changes in renal function and specifically for hypokalemia/hyponatremia related to the use of a diuretic and hyperkalemia or significantly elevated creatinine related to the use of an angiotensin receptor blocker (ARB). Initiation of angiotensin-converting enzyme (ACEI)/ARB therapy will result in a 20% increase in serum creatinine due to dilation of the efferent arteriole and decrease in glomerular pressure and should be expected on repeat lab testing. A creatinine increase of significantly higher than that should raise concern for a secondary process for acute renal failure. All patients started on either diuretic or ACEI/ARB therapy should have electrolytes and creatinine checked within a few weeks of starting the drug and monitored periodically thereafter.

This patient is severely underweight, is a chronic alcoholic, and likely suffers from chronic magnesium deficiency. Magnesium replacement is crucial in the treatment of patients suffering from alcohol withdrawal. Many patients with chronic alcoholism have clinically significant magnesium deficiency secondary to malnutrition and chronic diuresis from alcohol ingestion. Replacement with magnesium sulfate decreases total sedation required and decreases the incidence of seizures. Magnesium deficiency is marked by muscular and neurologic hyperactivity and can manifest as tachycardia, myoclonus, nystagmus, altered mentation, cardiac arrhythmias, psychosis, and hyperactive reflexes. Magnesium deficiency is crucial to recognize because magnesium levels are generally not checked on a standard metabolic profile.

true Magnesium replacement should be initiated in patients suffering from alcohol withdrawal.

Osgood-Schlatter disease is the most frequent cause of knee pain in children age 10 to 15 years.

true Most patients with Osgood-Schlatter disease respond to conservative care that consists of rest and avoidance of the offending activity. Nonsteroidal anti-inflammatory drugs may also be used, but have not been shown to shorten the course of the disease.

Bottom Line: Aortic regurgitation and murmurs are often easily distinguished on tests by cardiac phase, location, and quality. Murmurs and their associated valvular defects are able to be distinguished if the physiology of the cardiac cycle is understood. Notably aortic regurgitation is often found at the left sternal border rather than the traditional right upper sternal border.COMBANK Insight : Media inserts in question stems utilize both clinical and academic skills and therefore are becoming more common. Practicing discriminating between systolic and diastolic murmurs as well as identifying crescendos and decrescendo.

true Murmurs are often classified based upon characteristics including timing in the cardiac cycle, configuration, location/radiation, pitch, and intensity. As different pathologies may have characteristic patterns these are highly testable. For testing purposes often identifying the phase in cardiac cycle (systolic/diastolic/continuous), location, and quality are sufficient to answer most questions.The murmur described within the question stem is diastolic which immediately eliminates the majority of the distracting answers. The location of the left sternal border is historically indicative of tricuspid pathologies, but also is present in a ventricular septal defect, atrial septal defect, tricuspid regurgitation, and aortic regurgitation.The audio presents an early diastolic murmur with a rapid progressive decrescendo also consistent with aortic regurgitation. The phase, location, and qualities are summarized in the table below.

There is no screening test for ovarian cancer, but oral contraceptive pills, when taken for more than 5 years, have shown a decrease in the risk of ovarian cancer by 50%.

true Oral contraceptive pills have shown to decrease the risk of ovarian cancer by 50% in the general population when taken for five years. However, this decreased risk has not been shown in patients who are carriers of BRCA1 or BRCA2 mutations. The reason for the decreased risk is that when taking oral contraceptive pills, ovulation is inhibited. This patient has no contraindication to using oral contraceptive pills and does not have any family history of gynecological cancer. Other ways for this patient to decrease her risk of ovarian cancer is to carry a full-term pregnancy and breastfeeding. Contraindications to oral contraceptive pills would include uncontrolled hypertension, uncontrolled headaches, smoking, and age greater than 35 years, and a previous thromboembolic event or hypercoagulable state.

Bottom Line: Clonidine is an alpha-2 agonist with a known side effect of orthostatic hypotension.COMBANK Insight : Causes of orthostatic hypotension have been tested multiple times on COMLEX over the past year and should be an area of focus during your exam preparation. Understanding this topic could easily pick you up an extra 3-4 questions on exam day.

true Orthostatic hypotension is a physical finding defined by the American Academy of Neurology and the American Autonomic Society as a systolic blood pressure decrease of at least 20 mmHg or a diastolic blood pressure decrease of at least 10 mmHg within three minutes of standing. Several potential non-neurogenic causes of orthostatic hypotension include pharmacologic causes (e.g. TCAs, alpha-1 blockers), impaired venous return, hypovolemia, and cardiac insufficiency. Neurogenic causes such as multiple sclerosis and diabetic neuropathy can also cause this disorder.

Overflow incontinence is the involuntary release of urine—due to a weak bladder muscle or to blockage—when the bladder becomes overly full, even though the person feels no urge to urinate. Symptoms of overflow incontinence include: The sudden release of urine, a feeling of fullness in the bladder even after urination, leakage of urine while sleeping, a urine stream that stops and restarts during urination, and/or difficulty urinating even while feeling the urge to urinate. Overflow incontinence in both men and women can be caused by: Conditions that affect the nerves (such as diabetes or multiple sclerosis) and alter a person's ability to sense bladder fullness or that reduce the ability of the bladder to contract, a blockage in the urinary tract, such as a bladder stone or a urinary tract tumor that constricts the urethra, when blockage occurs in men, it is usually caused by an enlarged prostate gland (benign prostatic hyperplasia, or BPH), cancer of the prostate, or a narrowing of the urethra, weakness in the muscle that expels urine from the bladder (detrusor) so that it can't empty the bladder normally and certain medicines.In women, overflow incontinence can be treated with an intermittent self-catheterization where a woman inserts a clean catheter when it is necessary to urinate, usually 3 or 4 times a day or an indwelling Foley catheter which remains in place continuously. Urinary tract infections are more likely to occur with long-term use of an indwelling catheter than with intermittent self-catheterization. Surgery may be needed to correct problems that cause overflow incontinence, such as obstructions or abnormal growths in the urinary tract. Medicines are rarely used to treat overflow incontinence in women.Men can be treated for overflow incontinence with surgery. Overflow incontinence caused by an enlarged prostate is often treated with surgery to remove the obstruction, including transurethral resection of the prostate (TURP), a common procedure used to treat BPH. A catheter may also be utilized. Certain medicines can be used to make the prostate smaller. This relieves pressure on the urethra so the bladder can empty more normally.

true Overflow incontinence is the involuntary release of urine—due to a weak bladder muscle or to blockage—when the bladder becomes overly full, even though the person feels no urge to urinate.

Bottom Line: Pancreatic carcinoma for COMLEX purposes will often present in an African American male with the chief complaints of abdominal pain, weight loss, and migratory thrombophlebitis. On physical exam, the Courvoisier sign may be seen along with obstructive jaundice.

true Pancreatic carcinoma often presents clinically with mid-epigastric pain, weight loss, anorexia, and a palpable, nontender gallbladder (Courvoisier sign). Obstructive jaundice may be present if the carcinoma lies in the head of the pancreas. Migratory thrombophlebitis (Trousseau syndrome) is a less common finding but is present in this case. Pancreatic carcinoma is more prevalent in African American males, diabetics, and patients with a history of smoking. Approximately 75% of cases occur within the head or neck of the pancreas, 15% to 20% of cases are seen in the body, and 5% to 10% occur in the pancreatic tail. The median age for diagnosis is estimated to be 69 years for whites and 65 years for blacks.

Patellofemoral pain syndrome is a mechanical cause of knee pain that occurs because the patella does not glide well in the femoral groove. It is often caused my muscle imbalances such as gluteus and quadriceps weakness and hamstring tightness. Common symptoms occur when the patella makes contact with the femur. These symptoms can commonly be seen when the patient sits for prolonged periods (movie theater sign) or when the patient is climbing stairs. Pain can also commonly be seen on exam during the grind test. During this test, the provider places posterior pressure on the patella while having the patient contract their quadriceps muscle. This forces the patella into the femoral groove.

true Patellofemoral pain syndrome is a mechanical cause of knee pain that occurs because the patella does not glide well in the femoral groove. Maneuvers that force the patella deeper into the femoral groove will worsen symptoms.

Patellofemoral pain syndrome typically presents with anterior knee pain that worsens with prolonged sitting or with ambulation up or down stairs.

true Patellofemoral pain syndrome, also known as runner's knee, refers to anterior knee pain due to poor tracking of the patella over the distal femur. Symptoms typically include anterior knee pain that worsens while going up or down stairs and hills, or by prolonged sitting with knees flexed. The J-sign is named for the course of the patella tracking in the joint with contraction of the quadriceps. Patellofemoral syndrome is associated with weakness of the vastus medialis as compared to the vastus lateralis and leads to abnormal lateral tracking of the patella. Radiographs are usually normal. Initial treatment includes rest, ice, and analgesia followed by training with special attention to strengthening the vastus medialis.

Bottom Line: Pupil-involved third nerve palsy requires emergent evaluation with neuro-ophthalmology consultation and appropriate imaging as this may be indicative of a posterior communicating artery aneurysm.COMBANK Insight : Be familiar with some of the common nerve palsies and their manifestations.

true Patients presenting with a third cranial nerve palsy and loss of parasympathetic pupillary activity are likely to have an aneurysm at the junction of the posterior communicating artery and the internal carotid. At this location, the third cranial nerve travels in close proximity under the junction of the arteries. The parasympathetic fibers that control pupillary responses travel on the superomedial aspect of the third nerve are commonly affected first in such a lesion. A third nerve palsy consists of a complete ptosis and a down-and-out appearing eye. The extraocular muscles affected are the levator palpebrae superioris, superior rectus, medial rectus, inferior rectus, and inferior oblique muscle. The superior oblique muscle is innervated by cranial nerve four, the trochlear nerve. The lateral rectus is innervated by cranial nerve six, the abducens nerve. Gold standard imaging includes catheter angiography to detect aneurysms, with either computed tomography angiography or magnetic resonance angiogram.

Cobb angles of greater than 75º involving the thoracic spine are associated with a cardiovascular compromise. In addition, there is no evidence of or risk for underlying cardiac disorder.

true Patients with a Cobb angle of more than 50º have severe scoliosis. Patients with a curve involving the thoracic spine of greater than 50º often have a compromise of respiratory function while patients with a curve of greater than 75º often have a compromise of cardiovascular function. Respiratory dysfunction is often seen in a restrictive pattern. A pulmonary function test would provide information regarding a potential respiratory compromise and may influence the decision regarding the benefit of surgical intervention on the spine for this patient.

Bottom Line: Exposure to cigarette smoke and radon is associated with an increased risk of lung cancer, especially small cell carcinoma.COMBANK Insight : Occupation exposures and their long-term sequela have become a commonly tested topic.

true Patients with small cell carcinoma present with symptoms such as shortness of breath, chronic cough with rapid worsening of symptoms, bone pain, weight loss, fatigue, and even seizure if the patient has brain metastases. Small cell carcinoma is usually centrally located and may cause irritation, obstruction, or both of the major airways. Common symptoms resulting from local tumor growth include cough, dyspnea, and hemoptysis. It is an extremely fast-growing cancer that is expected to have metastasized by the time of diagnosis. Treatment consists of chemoradiation; only very early localized small cell is amenable to surgical resection.Risk factors include mainly smoking and radioactive damage. The main use of uranium in the civilian sector is to fuel nuclear power plants. Radon is a naturally occurring decay product of uranium. It is a colorless, odorless, chemically inert gas. Radon decays to products that emit heavy ionizing alpha particles, which may damage the DNA in respiratory epithelial cells. Radon exposure increases the risk of developing lung cancer, usually the small cell type. Among uranium miners who smoke, the risk of developing lung cancer is ten times greater than that of their nonsmoking colleagues. Osteopathic Pearl: A Chapman point represents the somatic manifestation of a visceral dysfunction. Most posterior Chapman reflex points are located between the spinous and transverse processes; they have a rubbery texture when palpated. The Chapman reflex points related to the upper and lower lungs are located at the right T3-T4 intertransverse spaces, respectively. Once a Chapman point is localized, firm pressure is applied to the point. Pressure is applied in a circular pattern with the attempt to flatten the mass, and is continued until the lesion is resolved or the patient can no longer tolerate treatment.Rib dysfunctions are a type of somatic dysfunction in which movement or the position of a rib is altered or disrupted. This can be seen with a single rib, or it can be a group dysfunction. In a group dysfunction, there is usually one rib that is responsible for causing the dysfunction, referred to as the "key rib". This particular case is describing an exhalation dysfunction. In an exhalation dysfunction, the dysfunctional ribs will move caudad during exhalation; however, the dysfunctional ribs will not move cephalad during inhalation. The rib will appear to be "stuck down." In ribs with bucket handle motion (ribs 6-10), there will be lateral narrowing of intercostal space below the dysfunctional rib in an exhalation dysfunction. Lastly, in a group exhalation dysfunction, the key rib is the uppermost rib (in this case, rib 6 on the right).

This question is testing your understanding of the various phases of clinical trials, which range from phase 0 to IV. In phase IV, the drug has already been approved by the US Food and Drug Administration (FDA). This means it will be used by a much larger population than could practically be included in any clinical trial, so rare side effects that may not show up in a small group could occur in the wider population. The drug is carefully monitored as the population of use grows. This ongoing data collection is known as phase IV of clinical trials.

true Phase III trials are when the drug is compared to the current standard of care. If it is safe (phase I) and it works (phase II), the researchers can determine if it works better than what is currently used. Randomized clinical trials are usually phase III. All clinical trial phases are in people. Mouse models are preclinical. Phase 0 trials give a small dose of the drug to 10 to 15 people to understand how it is processed by the body.

HZV is a common cutaneous viral infection that results from reactivation of the dormant varicella virus in the dorsal root ganglia. Skin lesions appear as erythematous plaques that progress to vesicles, and then pustules, which finally crust and fall off. T-cell immunity is an important component to virus suppression and is one reason why incidence increases with age. Logically, HZV can be an early clinical sign of the development of AIDS in high-risk individuals. Active HZV infection can be treated with acyclovir

true Pregabalin is a first-line FDA-approved treatment for post-herpetic neuralgia (PHN). The other first-line FDA-approved treatments are lidocaine skin patch 5% or capsaicin cream. The most common side effects of pregabalin are somnolence, dizziness, ataxia, and peripheral edema. Gabapentin may also be utilized in the treatment of PHN. Other first-line therapies for PHN include tricyclic antidepressants (amitriptyline, nortriptyline, etc), tramadol, and SNRIs.

Addison disease (primary adrenal insufficiency) commonly presents with weight loss, muscle weakness, fatigue, hypotension, and hyperpigmentation of the skin.

true This is a classic presentation of Addison disease (aka: primary adrenal insufficiency, hypocortisolism or hypocorticism) characterized by weight loss, muscle weakness, fatigue, and hypotension. Most people with primary Addison disease also have hyperpigmentation of the skin, including areas not typically exposed to the sun. Sites of hyperpigmentation include areas of skin creases (e.g. of the hands), face, nipples, and buccal mucosa. The pathophysiology of hyperpigmentation in Addison disease is important and occurs due to the fact that melanocyte-stimulating hormone (MSH) and adrenocorticotropic hormone (ACTH) share the same precursor molecule. Therefore, an increase in ACTH production also increases MSH. However, cortisol is decreased, causing the drop in blood pressure. Addison disease is often associated with other autoimmune comorbidities, such as vitiligo. The most common electrolyte abnormalities in patients with Addison disease are hyperkalemia and hyponatremia.

Bottom Line: Psoriasis characteristically appears as nonpruritic, well-demarcated, erythematous plaques with silvery-white scales on extensor surfaces.COMBANK Insight : Remember the Auspitz sign of psoriasis, which is pinpoint bleeding with removal of the overlying scale.

true Psoriasis is a common, chronic, inflammatory disorder of the skin and joints that affects nearly 7 million persons nationwide. Not all cases of psoriasis itch, and it is commonly estimated that some 10%-40% of patients have no pruritis with psoriasis. The etiology is multifactorial, and both genetic and environmental factors lead to the development of the disease. Factors that may exacerbate psoriasis include human immunodeficiency virus (HIV) infection, physical trauma, infections, drugs, and the winter season. Psoriasis characteristically appears as red scaly patches on extensor surfaces of the skin. The scaly patches caused by psoriasis, called psoriatic plaques, result from areas of inflammation and excessive skin production that rapidly accumulate at these sites and take a silvery-white appearance. Although plaques frequently occur on the skin of the elbows and knees, they can affect any area of the body, including the scalp and genitals. Psoriasis may affect the scalp and nails, and may also cause psoriatic arthritis, which affects 5%-8% of psoriatic patients. Treatment includes the use of topical corticosteroids, phototherapy, tazarotene, anthralin, methotrexate, cyclosporine, and biologic agents in severe cases.

The patient has evidence of diabetic ketoacidosis, or DKA. DKA is defined by the International Society for Pediatric and Adolescent Diabetes (ISPAD) as the presence of all of the following, in a patient with diabetes (this patient likely has undiagnosed diabetes):1. Hyperglycemia with blood glucose > 200 mg/dL2. Metabolic acidosis with serum bicarbonate < 15 mEq/L or venous pH < 7.33. Ketosis - presence of ketones in blood or urineDKA is a significant cause of morbidity and mortality in children with diabetes, occurring in 6 to 8 percent of diabetic children per year. DKA occurs when there is a relative or absolute deficiency of insulin, resistance to the insulin hormone, or glucagon excess, which may be in part due to a lack of insulin. Insulin deficiency leads to lipolysis, or breakdown of fatty tissue, to fatty acids. These fatty acids are transported to the liver, which may then form acetoacetic acid, otherwise known as a ketone body. Acetoacetic acid may be further broken down to beta-hydroxybutyric acid or acetone. These ketones provide an alternative energy source when glucose is unable to be utilized due to a hypo-insulinemic state in DKA.Classic symptoms of DKA include polyuria, polydipsia and fatigue. Patients frequently have vomiting, abdominal pain, and anorexia. Kussmaul respirations, a respiratory pattern with hyperventilation and deep respirations, may be seen as a way to compensate for the metabolic acidosis seen with DKA. This is likely the cause of this patient's apparent shortness of breath. In addition, neurologic manifestations may be seen with severe DKA, including altered mental status, lethargy, or coma with or without cerebral edema. In addition to the laboratory abnormalities listed above, the anion gap is usually elevated, with a normal anion gap in children ranging from 10-14. Serum sodium may be decreased, due to the hyperosmolar effects of hyperglycemia, causing a hyperosmolar hyponatremia. Due to the relative deficiency of insulin, potassium may be normal or slightly elevated, as insulin shifts potassium intracellularly. However, treatment of DKA with insulin and IV fluids will decrease serum potassium, which may need to be replaced during treatment.Treatment of DKA should begin promptly upon diagnosis. The mainstays of treatment are volume expansion with intravenous fluids, insulin infusion (generally begins at 0.1 units/kg/hour), electrolyte replacement as indicated (especially potassium), serial monitoring of electrolyte and blood glucose levels, as well as cardiac and neurologic monitoring. Patients with DKA should be admitted to the hospital, possibly to the intensive care unit, as they require close monitoring to ensure clinical improvement.

true Recognition and prompt treatment of DKA in children is essential. DKA can be life threatening. Always consider non-respiratory causes of shortness of breath when evaluating a child.

Bottom Line: In certain high-risk populations, rifaximin is the preferred antibiotic prophylaxis for traveler's diarrhea.COMBANK Insight : Preventive medicine is widely tested on COMLEX and is high yield information to study.

true Rifaximin is currently recommended for prophylaxis against traveler's diarrhea. Certain high-risk groups, such as the elderly, immunocompromised, or those with chronic gastrointestinal diseases, may benefit from antibiotic prophylaxis. In the 1980s and 1990s, fluoroquinolones were popular for this purpose. However, particularly in southeast Asia, significant antibiotic resistance has developed, and drugs such as ciprofloxacin are no longer recommended for prophylaxis against traveler's diarrhea. In addition, fluoroquinolones have other side effects such as QT prolongation and risk of tendinopathy. Azithromycin is a possible substitute for rifaximin. The most important advice to anyone traveling abroad is to be careful with what they eat. Many foods can be washed in unpurified water, as is common with fresh vegetables and fruits. Sometimes, water itself is not purified, and drinking bottled water or bringing a filter can help. Cooked food will generally be safe if it is still hot, and fruit should be peeled. Obviously, dairy products should be pasteurized. Ice is often not purified, so drinks should be obtained without ice if they are otherwise bottled. Alcohol at levels consumed is not sufficient to sterilize water or drinks.

Bottom Line: The CDC guidelines state that influenza vaccinations are recommended for everyone above 6 months of age annually, and herpes zoster vaccinations are administered at age 60 or above, unless they have underlying chronic medical conditions. A tetanus vaccine is given once every ten years, with the Tdap vaccine administered as a one-time dose in place of the Td booster every ten years for adults up to age 65 who have not previously received the Td vaccine. Pneumococcal vaccine is indicated in patients over 65 years of age or with chronic medical conditions.

true Screening tests and vaccinations are very high yield for the COMLEX. According to the Centers for Disease Control and Prevention (CDC), routine influenza vaccinations are recommended for everyone above the age of six months. Another appropriate answer would be the herpes zoster vaccine, which was not given. Per the CDC, herpes zoster vaccination is recommended for all adults aged 60 or above, in addition to persons with chronic medical conditions. Other screening tests for this population include abdominal ultrasound for men aged 65-75 with a history of smoking at least 100 cigarettes in their lifetime, to screen for abdominal aortic aneurysm.

Bottom Line: Patients with an infected joint typically present with the triad of fever, pain, and impaired range of motion. They are toxic appearing with laboratory values suggesting an active infection (including elevated white blood cell count, erythrocyte sedimentation rate, and C-reactive protein). This is in contrast with toxic synovitis, in which there is no active infection.COMBANK Insight : An approach to a rapid evaluation of an acutely inflamed joint is to screen the synovial fluid for crystals via polarizing microscopy and for organisms via Gram stain.

true Septic arthritis may represent a direct invasion of joint space by various microorganisms, most commonly caused by a variety of bacteria. Patients with an infected joint typically present with the triad of fever (40%-60% of cases), pain (75% of cases), and impaired range of motion. Children are typically toxic appearing, with a significant resistance to all weight bearing or motion. The most commonly involved joint in septic arthritis is the knee (50% of cases), followed by the hip (20%). A thorough inspection of all joints for signs of erythema, swelling (90% of cases), warmth, and tenderness is essential for diagnosing infection. Infected joints usually exhibit an obvious effusion, and ultrasound-guided aspiration of fluid with positive cultures is required for diagnosis.

A hip fracture which occurs from a standing height is considered a fragility fracture and indicator of osteoporosis. Hip fractures are a significant contributor to morbidity and mortality in the elderly and depending on the situation are associated with increased mortality of 10-20%. Because of this, prevention and treatment are critical. In this situation, this patient has already fractured so the focus should be on treating her appropriately now and preventing future fractures by treating her osteoporosis. All patients with a hip fracture secondary to a low energy mechanism should receive a bone health work up to include a vitamin D and calcium level and DEXA scan as a baseline. Additionally, following surgical fixation of a hip fracture, patients should be mobilized with physical therapy (within the restrictions of their surgeon) as earlier mobilization improves outcomes with decreased length of hospital stays and decreased in-hospital complications.The World Health Organization (WHO) established a classification of BMD according to the standard deviation (SD) difference between a patient's BMD and that of a young-adult reference population. This value is now commonly expressed as a "T-score." A T-score that is equal to or less than -2.5 is consistent with a diagnosis of osteoporosis, a T-score between -1.0 and -2.5 is classified as low bone mass (osteopenia), and a T-score of -1.0 or higher is normal.

true She had no bleeding events on admission and no signs of hemorrhage on her examination. There is nothing in this question to suggest she cannot resume her anticoagulant. In fact, she is high risk for the development of a DVT in the post-operative setting and given her atrial fibrillation, would benefit from resuming her anticoagulation. Additionally, falls should not be used as justification to withhold anticoagulation in the setting of atrial fibrillation. Many, many falls are required before the patient is at significant risk of intracranial hemorrhage. Some studies have estimated that a patient would need more than 295 falls per year before the risk of falls outweighed the risks of stroke.

Bottom Line: Management of vaginal candidiasis is typically with a 1-time oral dose of fluconazole.COMBANK Insight : The COMLEX will often present multiple "correct" answer choices, and you must choose the best answer of those presented. This is a classic example: oral fluconazole, topical fluconazole, and topical ketoconazole ALL treat vaginal candidiasis. In this situation, choose the best treatment out of those 3 options. Oral fluconazole is the most convenient treatment with 1-time dosing. In addition, to narrow down the options, you are presented with 2 topicals and 1 oral medication option; choose the outlier and treat with the oral medication.

true Single-dose oral fluconazole has recently been approved for the treatment of acute episodes of vaginal candidiasis and has been shown to be equally effective as traditional topical antifungal agents. Vulvovaginal candidiasis is the second most common cause of vaginitis. The patient's history includes vulvar pruritus, vaginal discharge, dysuria, and dyspareunia. Approximately 10% of women experience repeated attacks of vulvovaginal candidiasis without precipitating risk factors; however, use of oral antibiotics is associated with increased incidence of these infections. Physical examination findings include a vagina and labia that are erythematous along with a thick curd-like discharge.

The mechanism of TCA medications is inhibition of presynaptic neurotransmitter reuptake (norepinephrine and serotonin). In an overdose, observed cellular changes include: blockade of cardiac fast sodium channels, antagonism of central and peripheral muscarinic acetylcholine receptors, antagonism of peripheral alpha-1 adrenergic receptors, antagonism of histamine (H1) receptors, and antagonism of CNS gamma-aminobutyric acid (GABA) A receptors. Sodium bicarbonate is the standard first line treatment for hypotension and arrhythmias. Sodium bicarbonate helps by causing an increase in serum pH and the increase in extracellular sodium. The increase in serum pH makes the TCA less available to bind to sodium channels. The increase in the extracellular sodium concentration increases the electrochemical gradient across cardiac cell membranes, potentially attenuating the TCA-induced blockade of rapid sodium channels. Of note, if the patient were to be having seizures then benzodiazepines would also be used.

true Sodium bicarbonate is the mainstay of antiarrhythmic therapy in tricyclic antidepressant intoxication.

Bottom Line: Status asthmaticus requiring intubation would likely reveal a primary respiratory acidosis with an arterial blood gas revealing a low pH, elevated pCO2 (>60 mmHg), and decreased pO2 (< 60 mmHg).

true Stage 4 is the most likely stage this patient is currently in. He has exhibited hyperventilation [stage 2] progressed to hypoventilation, with the use of accessory muscles and appearance of fatigue, [stage 3] and after ten minutes is likely experiencing respiratory muscle insufficiency. Intubation and an optimal ventilation strategy are necessary as management in addition to continued administration of beta-agonists, smooth muscle relaxation agents such as magnesium sulfate and intravenous corticosteroids. Blood gas analysis is a necessary skill. Remembering normal ranges (pH 7.35 to 7.45; pCO2 35 to 45 mmHg; PO2 83 to 108 mmHg) and expected changes with certain conditions will go a long way. Carbon dioxide acts as an acid and thus an increase in CO2 will lower the pH, as in respiratory acidosis. Conversely, a decreased CO2 with a low pH likely represents a metabolic component to the acidosis.Osteopathic Pearl: Viscerosomatic reflexes are a type of somatic dysfunction caused by changes in the autonomic nervous system. They can be acute or chronic and are considered to be a somatic representation of visceral disease. When either branch of the autonomic nervous system (sympathetic or parasympathetic) over-stimulates a particular organ, a reflex reaction occurs. The soma at the same level of the organ's autonomic innervation takes on characteristics of somatic dysfunction (TART). T2-T7 is where the sympathetic viscerosomatic reflex for the lungs and pleura are located.

Superior mesenteric ganglion release can be used to treat irritable bowel syndrome (IBS). The celiac ganglion (T5-9 via greater splanchnic nerve) supplies the upper gastrointestinal (GI) tract (lower two-thirds of the esophagus to the ligament of Treitz). The superior mesenteric ganglion (T10-11 via lesser splanchnic nerve) supplies the middle GI tract (ligament of Treitz to the mid-transverse colon). The lower GI tract is supplied by T12-L2 via the inferior mesenteric ganglion and lesser splanchnic nerve.

true Superior mesenteric ganglion release can be used to treat irritable bowel syndrome (IBS). The celiac ganglion (T5-9 via greater splanchnic nerve) supplies the upper gastrointestinal (GI) tract (lower two-thirds of the esophagus to the ligament of Treitz). The superior mesenteric ganglion (T10-11 via lesser splanchnic nerve) supplies the middle GI tract (ligament of Treitz to the mid-transverse colon). The lower GI tract is supplied by T12-L2 via the inferior mesenteric ganglion and lesser splanchnic nerve.Irritable bowel syndrome (IBS) is a diagnosis of exclusion. Studies have shown that the ROME IV criteria has a sensitivity of 63% and a specificity of 95%. However, there remains to be a "gold standard" diagnostic modality in the diagnosis of IBS. The ROME IV criteria can generally be used alone, in young patients, without further diagnostic testing if there are no red flags for a more serious process, such as malignancy or inflammatory bowel disease such as hematochezia/melena, weight loss, or fevers. The Rome IV criteria for the diagnosis of IBS are listed below: 1) Recurrent abdominal pain for at least 1 day per week in the last 3 months and associated with at least two of the following- Related to defecation- Associated with a change in frequency of stool- Associated with a change in the appearance of stool2) Patient must meet the above criteria for 3 months with the onset of symptoms 6 months prior to diagnosis.

Bottom Line: Difficulty with blood glucose control using oral hypoglycemics in type 2 diabetics is an indication for the initiation of insulin therapy.COMBANK Insight : It is important to have a strong understanding of diabetes mellitus, including pathophysiology, genetics, treatments, and screening (eg, diabetic eye exams, urine microalbumin, and monofilament testing). Diabetes mellitus is important to board examiners because of its high prevalence as well as it being a strong risk factor for cardiovascular disease (recall that diabetic patients can have "silent" ischemia or myocardial infarctions). Know how to differentiate types 1 and 2 from each other and the differences in pathophysiology and genetics for each type.Also, be aware of different terminology that may show up on the COMLEX. You may see insulin-dependent or non-insulin-dependent diabetes instead of types 1 and 2. Keep in mind that non-insulin-dependent diabetic patients are type 2, but insulin-dependent diabetic patients may be either type 1 or type 2. If you do not understand the former statement, review the answer again for this question. Be ready to answer a battery of questions about diabetes mellitus on the COMLEX!

true The C-peptide level in this question is indicative of the amount of insulin being produced by the pancreas. In this case, the patient has a low C-peptide, which indicates low insulin production by the pancreas. Type 1 diabetic patients may have a normal C-peptide level during their "honeymoon" period (approximately the first week after diagnosis) but will have a low C-peptide level throughout the rest of their life. This indicates that the pancreas is not producing adequate amounts of insulin. Type II diabetic patients have developed an insulin resistance in the peripheral tissues; thus, the pancreas will produce increased amounts of insulin, causing the C-peptide to increase. Patients with type 2 diabetes may also develop inadequate insulin production by the pancreas as their disease progresses. Think of this as the pancreas becoming "burned out" from overproducing insulin in an attempt to compensate for the insulin insensitivity. Once the pancreas stops producing (or overproducing) insulin, patients will present with uncontrolled glucose and HbA1c levels. The next step in treatment of these patients is to begin insulin therapy. Knowing the pathophysiology of the disease assists greatly in answering this question correctly.

Mucormycosis is a group of fungi that can invade from adjacent sinuses and nasal cavities to involve the orbit. These nonseptate, branching, large hyphae will stain with hematoxylin-eosin and can invade the orbit and cause a thrombosing vasculitis and tissue necrosis. Diabetic ketoacidosis is a risk factor, as is an immunocompromised status. Mortality in patients with mucormycosis is high and prompts intravenous antifungal therapy, such as amphotericin B; tissue debridement; and possibly hyperbaric oxygen therapy. This is an emergent condition with a high mortality rate if untreated. There are 6 types of strains that can occur at the sphenobasilar synchondrosis (SBS): flexion/extension, torsion, sidebending/rotation, vertical strain, lateral strain, and compression. The osteopathic findings stated above describe a lateral strain. A lateral strain of the SBS is present when the sphenoid deviates laterally in relation to the occiput. If the sphenoid deviates to the left, it is termed a left lateral strain. If the sphenoid deviates to the right, it is termed a right lateral strain. Rotation will occur about 2 vertical axes, one through the center of the sphenoid and the other through foramen magnum. Palpation of a lateral strain will feel as if the cranium is shaped like a parallelogram.

true The CAGE questionnaire is a standard tool for assessing alcohol dependence in patients. CAGE stands for: Have you ever felt you should Cut down on your drinking?Have people Annoyed you by criticizing your drinking?Have you ever felt bad or Guilty about your drinking?Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (Eye opener)? Each question that is answered as a yes is 1 point. A score of 1 indicates the patient is at risk for alcohol dependence. A score of 2 to 3 points is highly suggestive of alcohol dependency. A score of 4 points is diagnostic for alcohol dependency.

Late decelerations are a worrisome event in pregnancy that results from uteroplacental insufficiency.COMBANK Insight : Being able to interpret fetal heart rate tracings is important for success on Level 3. You may be given a heart rate strip and asked to determine what type of deceleration is occurring, or you may be asked the physiology behind it or what the best treatment is.

true The FHT strip is representative of late decelerations caused by uteroplacental insufficiency. Late decelerations begin at the peak of a uterine contraction and return to baseline after the end of the contraction. They are worrisome and may warrant emergent delivery if bradycardia occurs or variability is lost. Fetal bradycardia with late decelerations warrants immediate caesarean section without delay. Persistent late decelerations with loss of beat-to-beat variability is an ominous sign and is an important indicator of fetal distress.

Bottom Line: In patients with occlusion of the middle cerebral arteries, clinical manifestations will include contralateral hemiparesis and hemisensory loss with the face and arm being more affected than the leg. They can also present with aphasia or neglect depending on whether the left or right MCA is affected and the patient's dominant hemisphere.COMBANK Insight : Strokes are among the most commonly tested subjects within neurology on level 3 exams. You must be able to localize the lesion and know how to treat it. Remember, a non-contrast CT is usually the first step in the management of a stroke.

true The MCA is one of the arteries that branches off the ICA. The MCA further divides into segments (M1, M2, M3, M4) to supply the lateral aspect of the cortex. This includes the basal ganglia, frontal lobes, and the superior temporal lobes. Occlusion of the MCA results in contralateral weakness (face, arm, and leg), with the arm being more affected than the leg, sensory disturbances, homonymous hemianopia, and a gaze preference towards the side of the lesion. In addition to that, neglect occurs with an occlusion of the right MCA and aphasia with a left MCA occlusion. In the question stem, the patient is having difficulties with language/speech production, which is a function of the left or dominant hemisphere from decreased blood supply to the language centers (Broca or Wernicke aphasia).This patient is presenting with classic symptoms of a stroke. An occlusion of the left middle cerebral artery would result in contralateral (right) hemiparesis and hemisensory loss (face/arm > leg). The patient is also presenting with Wernicke aphasia, which is also be found in a middle cerebral artery occlusion. Remember the homunculus map or topographical representation of sensory and motor areas in the cerebral cortex. This can be used to map lesions and determine which specific defects are likely. Different areas affected by a lack of blood flow will lead to different signs and symptoms. Treatment is dependent on the time of onset and patient risk factors. Intravenous tissue plasminogen activator can be administered in an ischemic stroke, within three hours if there are no contraindications. In addition to that, it has also been approved for administration between 3 to 4.5 hours for an acute ischemic stroke with additional guidelines for a select population. Thrombectomy and certain interventions can be considered depending on the clot size and symptoms.

Bottom Line: The treatment of squamous cell carcinoma of the anal canal is a combination of chemotherapy and radiation (Nigro protocol).

true The Nigro protocol is the standard of care for the management of squamous cell carcinoma of the anal canal. The patient should receive a combination of Mitomycin C and 5-FU. The patient receives concurrent radiation therapy. Surgery is not the primary modality as there is no survival benefit and combination chemotherapy and radiation preserve the anal sphincter. Abdominal perineal resection (APR) can be considered as salvage therapy for recurrence or persistent disease. It is important to distinguish anal canal cancers from anal margin cancers. Anal margin cancers are treated with wide local excision. Anal adenocarcinoma is treated in a similar fashion to rectal adenocarcinoma with surgery. The risk of anal cancer is higher in MSM, people with HIV/AIDS, and is more common in middle-aged women. Symptoms include anal bleeding, pain, the sensation of a perianal mass, and sometimes pruritus. An abdominal perineal resection (APR) includes the resection of the sigmoid colon, rectum, and anus, and the construction of a permanent colostomy. This is the gold standard for surgical therapy of low-lying rectal cancers, and it remains the standard against which sphincter-sparing procedures (SSP) and local excision procedures are compared. In the past, APR was routinely performed for tumors arising in the anal canal. This radical procedure requires removal of the anorectum, lymph node resection, with the creation of a permanent colostomy. Five-year survival rate after this procedure was 55-70% without local lymphatic spread and less than 20% if nodal involvement was found.'' A low anterior resection (LAR), is used to surgically treat invasive cancers located in the upper to middle third of the rectum. This is not a treatment for anal cancer; however, a very low anterior resection can be used for neoplasm in the distal rectum if the margins are clear of malignant cells.

Ventriculoperitoneal shunts most commonly become infected in the weeks following placement due to colonization of skin flora. The most common pathogen is Staphylococcus epidermidis, which is coagulase-negative and should be initially treated with vancomycin.

true This boy has an infected ventriculoperitoneal shunt. He is presenting with vital signs concerning for severe sepsis, while his headache and vomiting are likely due to increased intracranial pressure. The leukocytosis with a left shift indicates a likely bacterial infection. Shunts most commonly become infected in the weeks following placement as they become colonized with skin flora. Staphylococcus epidermidis, which is coagulase-negative, is the most common bacteria to colonize the shunt and lead to infection.Of note, fever, headache, and vomiting are common signs of a shunt infection. However, a patient with an infected shunt may also be asymptomatic ifthe shunt is working as it disrupts the communication between the infected ventricles and the meninges. In the question above, the boy's shunt is likely blocked by infection as he has symptoms concerning for rising intracranial pressure. Most common pathogens for CNS pathology: Brain abscess: Viridans streptococci and Staphylococcus aureus Shunts: Staphylococcus epidermidis Meningitis: Group B Strep (19 years), N. meningitidis (10 years - 19 years)

Bottom Line: Self-consciousness related to pubertal development is most common between the ages of 10 and 15 years.COMBANK Insight : If you are finding it hard to believe that we actually asked this question on our COMLEX question bank, don't worry, we are too. Believe it or not, you are going to encounter at least one off-the-wall question on childhood psychology when you sit for your real exam. This very topic was tested in recent years and is one that could easily show up again. When in doubt, use your common sense to answer these questions as you are unlikely to find the answers in any book you will read. Do not be surprised if you encounter a few questions like this that are totally unrelated to anything you have studied in your medical training. Just answer them and move on.

true The age group of 10 to 15 years comprises the largest group of pubertal patients, for both males and females. It is during this time when it would be most expected for males and females to be self-conscious regarding the size of their genitalia. In general, puberty typically begins between the ages of 9 and 14 for girls and 10 and 15 for boys; however, these numbers can vary slightly depending on the source. Puberty is considered early (precocious) if it occurs before the age of 8 years in girls and 9 years in boys. Conversely, puberty is considered late or delayed if it has not begun prior to the age of 14 years for girls and 15 years for boys. The first sign of puberty in girls, which occurs at an average age of 10 1/2 years, is breast development (thelarche).

Bottom Line: A young child who is suddenly pulled up too hard by the hand or wrist, with subsequent crying and refusal to move the arm, is a typical presentation for a diagnosis of subluxation of the radial head (nursemaid's elbow).COMBANK Insight : This tends to be a favorite question that is asked over and over again and can be diagnosed based on the scenario alone.

true The clinical history is consistent with a child who has sustained a subluxation of the radial head, also known as "nursemaid's elbow". Due to their skeletal immaturity, the radial proximal radial head of a child can dislocate from the annular ligament when a significant distraction force is applied to it, often times in scenarios similar to the one presented here. Radial head subluxation is the number one injury to the upper extremity in children. Bottom Line: A child with a radial head subluxation will be holding the arm in a slightly flexed position at the elbow, and pressed up against his body. Although there are multiple ways to reduce the radial head, the most successful and least painful method is hyperpronation with the elbow at 90 degrees of flexion. The alternative technique is supination at 90 degrees followed by flexion.

Bottom Line: A late deceleration is a gradual decrease and increase of the fetal heart rate, where the nadir is located after the peak of the contraction, which indicates uteroplacental insufficiency.

true The fetal heart strip in the exhibit contains late decelerations. A late deceleration is when there is a gradual decrease of the fetal heart rate and a gradual return to the baseline taking longer than 30 seconds. The nadir of this type of deceleration occurs after the peak of the contraction. This type of deceleration indicates uteroplacental insufficiency. Bottom Line: When late decelerations are seen on the fetal heart tracing, the next step is to change the maternal position, discontinue oxytocin, add IV fluids, and place the patient on oxygen.

Bottom Line: The latent phase of the first stage of labor begins with the onset of labor and ends when the cervix is 4 cm dilated.COMBANK Insight : Stages of labor are easy to remember and will likely get you easy points on test day.

true The fetal heart tracing shows early decelerations, which indicates head compression. This can be commonly seen in the active stage of labor and when the patient is pushing. This type of deceleration has a gradual decrease in the fetal heart rate, with the onset to nadir taking greater than 30 seconds. Early decelerations begin with contractions and the nadir occurs at the same time as the peak of the contraction. These contractions are benign.

Pediatric patients who show inappropriate growth or a drop in weight-for-age percentiles across multiple time points can be said to have failure to thrive.

true The growth curve above demonstrates a patient with failure to thrive or weight faltering. The patient's initial weight was near the median and over the past few time points has failed to rise as expected based on the standard-growth curve data. The patient is now somewhere near the first to fifth percentile of weight-for-age. Failure to thrive (FTT), also sometimes now called weight faltering, is a term used to describe a pattern of inappropriate growth over multiple repeated measurements, and is generally indicative of some underlying process. While there is no agreed upon single percentile for the diagnosis of FTT, it is often used to describe infants and children with weight below the 5th percentile and is generally supported by a decrease in growth velocity in which weight-for-age or weight-for-height falls by at least two major percentile markers (95, 90, 75, 50, 25, 10, and 5)The diagnosis of FTT in a child should prompt an evaluation for the cause of undernutrition. Causes are variable and can include neglect, food insecurity, or patient medical conditions which may prevent adequate intake of nutrients. Rarely, there may be underlying conditions which may cause increased metabolism or decreased absorption. To accurately document patient weight changes, there must be multiple points on the curve. One reading is not enough to document FTT. It is recommended that the WHO growth charts be utilized for measurements in children 0-2 years and that after that, providers transition to the CDC growth curves for patients 2-20 years of age. While inability to maintain the appropriate weight is the predominant symptom of FTT, severe malnutrition can impair overall growth. While weight is affected, continued lack of appropriate nutrition can result in lagging length and head circumference and if severe enough, developmental and cognitive delay.

The orbital floor is the most common site of orbital fractures secondary to blunt trauma and can result in diplopia due to a trapped inferior rectus muscle.

true The inferior rectus is likely entrapped in an orbital floor fracture. The most common site of orbital fractures is in the posterior medial floor of the orbit. The inferior rectus, when entrapped, can lead to restriction in vertical movement, especially in upgaze. This results in a diplopia when the patient attempts to look in various directions. Sensation in the upper cheek and lower eyelid should be evaluated since the V2 branch of cranial nerve V courses in the floor of the orbit. The inferior rectus muscle is supplied by cranial nerve III, the oculomotor nerve. Additionally, other nerves may be injured in addition to these. Hypoesthesia may result from damage to the infraorbital nerve. Enophthalmos can also result from herniation of orbital contents through a fracture. A diagnosis of a trapped inferior rectus muscle will require evaluation by an ophthalmologist.

Bottom Line: The drug of choice for the prophylaxis of infective endocarditis is amoxicillin in non-penicillin allergic patients, to be taken sixty minutes prior to the procedure.

true The most common cause of endocarditis that results from dental procedures is Strep viridans (alpha-hemolytic strep). The recommended prophylaxis is a single dose of 2 g Amoxicillin given 30-60 minutes prior to the procedure. Azithromycin is an alternative in penicillin allergic patients. Penicillin VK is equally effective in vitro against alpha-hemolytic strep, however, amoxicillin has better gastrointestinal absorption and therefore is the preferred drug.

Mesenteric angiography is the definitive diagnostic test for acute mesenteric ischemia and can be used for both diagnosis and treatment.

true The most definitive test for the diagnosis and treatment of mesenteric embolus is mesenteric angiography with interventional radiology. The most commonly ordered and generally felt to be the best first-line test is a CT angiogram, which was not one of the answer options.If a patient is hemodynamically stable without peritoneal signs, a CT angiogram of the abdomen and pelvis should be performed, which will typically show evidence of ischemia. If there is still uncertainty regarding the diagnosis or it is felt that the lesion on CT is amenable to endovascular intervention with interventional radiology, an angiography should be ordered. During angiography, vasodilators, thrombolytics, stent placement, or embolectomy can be used to assist in treatment. If interventional radiology is unable to perform this intervention or the patient becomes clinically unstable, then you should take the patient to the operating room for an emergent exploratory laparotomy and resection of necrotic bowel.Mesenteric angiography will show a proximal defect of a mesenteric vessel secondary to either embolus, thrombus, or volvulus. These are all causes of occlusive ischemia. It may also show vasoconstriction of all mesenteric vessels if it is due to nonocclusive ischemia. In this case, the cause could be generalized low blood flow with more of a watershed pattern of ischemia or due to a vasoconstrictive medication such as cocaine or epinephrine; however, this would be rare.

Bottom Line: Carbonic anhydrase inhibitors, such as acetazolamide, are used as an initial first-step to preserve vision and prevent blindness in patients with BIH.

true The most likely diagnosis in this patient is pseudotumor cerebri, also known as benign intracranial hypertension (BIH). It presents with papilledema in the absence of any tumor or obstruction of cerebrospinal fluid (CSF) flow. Most patients will have a normal mental status exam and a normal physical exam without any focal neurologic signs. Risk factors for developing BIH include use of vitamin A, hypothyroidism, Cushing's disease, isotretinoin, and tamoxifen use. It usually presents with headaches, double vision, and blurry vision. Treatment begins with carbonic anhydrase inhibitors such as acetazolamide (most effective). Carbonic anhydrase inhibitors are thought to decrease CSF production. Loop diuretics may also be used. Corticosteroids for treating BIH is controversial as they can cause weight gain, which is a risk factor for BIH. Weight loss may improve symptoms. The patient's medical history should also be reviewed to identify conditions or drugs that are associated with BIH such as untreated obstructive sleep apnea and tetracycline use.The main goals of treatment are to improve patient symptoms (headache) and to preserve and improve vision. If not treated, blindness may result. If medical management is contraindicated or if medical management fails, an optic nerve sheath fenestration can be used to relieve pressure on the optic nerve. Other possible procedural interventions for BIH include CSF shunting, serial lumbar punctures, and venous sinus stenting. Medications can also be used to control headache symptoms.

Bottom Line: Tabes dorsalis and dilated thoracic aorta are classic findings for tertiary syphilis. Penicillin is the treatment of choice for treating syphilis and can prevent progression to tertiary syphilis.

true The most likely diagnosis is tertiary syphilis. This occurs years after an untreated primary infection. Treatment with penicillin during the primary and secondary phases prevents progression to the tertiary stage. His neurologic symptoms are due to demyelination of the posterior columns (tabes dorsalis). Dilated saccular aneurysm of the thoracic aorta can also be found in patients with this disease.

The string of an intrauterine device (IUD) should always be visible on speculum exam if it has been properly placed. The most likely explanation for not seeing the string during visual examination is that the string has moved into the cervical canal or the uterine cavity or it has been expelled. The first step in this setting is to perform a pregnancy test. If the woman is not pregnant, a cytobrush can be used to draw the string out of the endocervical canal with or without the aid of uterine ultrasound or endocervical speculum. If these measures fail to yield the string, an ultrasound should be done to see whether or not it has moved into the uterine cavity, and interim contraception should be provided until the ultrasound is performed. Normal or irregular menstrual cycles should not affect the location of an intrauterine device.

true The most likely explanation for not being able to see the string of an intrauterine device (IUD) is that it has fallen out or has moved into the uterine cavity. Because the next step is exploring the endocervix, which could compromise a growing fetus, you should always perform a pregnancy test first.

Bottom Line: The vector for Borrelia burgdorferi (the spirochete responsible for Lyme disease) is the Ixodes tick. Reservoirs are white-footed mouse and white-tailed deer. The Ixodes tick is, however, the vector for a variety of diseases. It is important to keep coinfections in mind when treating Lyme disease and especially when initial treatment does not resolve symptoms.

true The patient above has a erythema chronicum migrans rash that is characteristic for early localized Lyme disease. Lyme disease is caused by the spirochete Borrelia burgdorferi, which is transmitted by the bite of the Ixodes tick. It is most common in the Northeast, Midwest, and Northwest United States. Transfer takes at least 24 hours of attachment by the tick. The animal reservoirs for B. burgdorferi are the white-footed mouse and white-tailed deer. Patients who have been diagnosed with an Ixodes-borne infection should be evaluated for coinfection if they do not respond to standard antibiotic therapy. Other infections carried by the Ixodes tick in the United States include Anaplasma phagocytophilum, deer tick virus, and Babesia microti. Patients with Lyme disease and babesiosis may experience a greater number of acute symptoms for a longer duration than patients with Lyme disease alone.Symptoms for the infections carried by the Ixodes tick may be similar and overlap. However, the erythema chronicum migrans rash that is characteristic for early localized Lyme disease and should be part of the answer. The peristent symptoms despite treatment should lead you to believe a coinfection may be involved.

Bottom Line: A trial of oral rehydration is recommended as the first step for mild dehydration in a child who is able to tolerate fluids.

true This child is experiencing mild dehydration, likely due to gastroenteritis. Since the child is not actively nauseous or vomiting, a trial of oral rehydration is the best choice. Intravenous rehydration would be warranted if the child showed more severe signs of dehydration (poor skin turgor, sunken eyes, cold hands/feet, tachypnea, tachycardia) or if the child was unable to drink fluids. For gastroenteritis, antibiotics or antiviral agents are generally not necessary, especially as initial management options. Further, the presenting problem to manage is dehydration, as opposed to an infection. Antidiarrheal agents are generally not recommended in children with diarrhea, per the American Academy of Pediatrics (AAP).

According to the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines, hypertensive emergency is defined as significantly elevated blood pressure (systolic blood pressure >/= 180 or diastolic blood pressure >/= 120), in addition to end-organ damage such as papilledema, chest pain, or hematuria. This patient has no signs of end-organ damage, so she does not qualify for hypertensive emergency. Rather, she has elevated blood pressure without end-organ damage, often previously called hypertensive urgency. This terminology is not used as often due to confusion. Many cases of hypertensive urgency may actually represent chronic, stable, hypertension and if no end-organ damage is apparent, then urgent blood pressure lowering is not required. However, if chronic hypertension is not present, this presentation is still a serious problem and requires evaluation.

true The patient appears to be symptomatic from her elevated blood pressure; this now qualifies as a hypertensive emergency. Blood pressure lowering should be accomplished using IV therapy. The aim of treatment is to rapidly lower the diastolic pressure to 100-105, which should be achieved within two to six hours, with the maximal initial fall in blood pressure not exceeding 25% of the presenting value. More aggressive blood pressure control is not helpful and may lead to ischemic events. Close monitoring on telemetry is generally necessary. There are a variety of options available to treat hypertensive emergencies, and some are preferred in certain scenarios. IV nitrates (nitroprusside), IV calcium channel blockers (clevidipine), and IV beta blockers (labetalol) have all been used with success. There are no head-to-head studies showing clear benefit of one over another. Sublingual calcium channel blockers should never be used as they have been associated with severe ischemic events due to unpredictable blood pressure lowering.

Epstein Barr virus may be implicated in the development of Hodgkin lymphoma.

true The patient described in the clinical scenario above presents with night sweats, weight loss and a new mass concerning for malignancy. Hodgkin lymphoma usually presents as a painless mass that is nontender with a rubbery consistency and then can spread to contiguous lymph nodes. The most common site involved is the neck, although about 60-70% of patients also have mediastinal lymphadenopathy. Many patients will also complain of B symptoms which include fever, night sweats and weight loss. Many epidemiologic studies have demonstrated an increased risk of Hodgkin lymphoma in patients with a history of infectious mononucleosis, and some studies have shown detection of Epstein Barr virus (EBV) in the tumor cells of these patients. Osteopathic Pearl: Rhythmic impulses that can be palpated on the human skull exist and are referred to as the cranial rhythmic impulse (CRI). The CRI is normally 8-12 cycles per minute. There are factors that increase and decrease the rate and quality of the CRI. Factors that will decrease the rate and quality of CRI: Stress (emotional or physical) Depression Chronic fatigue Chronic infections Factors that increase the rate and quality of the CRI: Vigorous physical exercise Systemic fever Following OMT to the craniosacral mechanism CV4 is a craniosacral treatment that can enhance the amplitude of the CRI. It is done by first resisting the flexion phase and encouraging the extension phase of the CRI until a "still point" is reached, then allowing the restoration of normal flexion and extension to occur.

Acrodermatitis enteropathica is a rare form of zinc deficiency that presents with periorificial and acral dermatitis, alopecia, and diarrhea. It often presents with cessation of breastfeeding and can be life threatening if untreated.

true The patient is suffering from acrodermatitis enteropathica (AE), a rare inherited form of zinc deficiency that presents in infants following the discontinuation of breastfeeding. It is an autosomal recessive metabolic disorder characterized by periorificial and acral dermatitis, alopecia, and diarrhea. Diagnostic testing includes measuring plasma zinc levels, with a level of <50 μg/dL being suggestive of AE. Treatment involves daily zinc supplementation, without which death may occur within years. The recommended replacement dose is 3 mg/kg/d of elemental zinc or 13.2 mg/kg/d of zinc sulfate. Zinc levels should be measured every 3 to 6 months, and the dose is adjusted in response.

Bottom Line: Acute spasm of the sternocleidomastoid can result in torticollis.COMBANK Insight : Questions on Level 3 exams may be based on a medical case but give you osteopathic physical exam findings.

true The patient is suffering from acute spasm of the sternocleidomastoid (SCM). The SCM originates from the mastoid process and lateral aspect of the superior nuchal line and has sternal and clavicular attachments. The SCM muscles can act individually or together. Individually, the SCM will sidebend the head to the ipsilateral side with rotation to the contralateral side; when acting together, they will draw the head forward. Spasm of the SCM muscle can cause torticollis. Thoracic outlet syndrome is typically caused by compression of the brachial plexus and subclavian artery between the anterior and middle scalenes, between the clavicle and the first rib, or under the pectoralis minor. Symptoms include paresthesias and a cool sensation in the arm.

Bottom Line: Lorazepam is the first medication that should be used to treat status epilepticus. Alternatives are diazepam and midazolam.COMBANK Insight : A patient who does not recover from the post-ictal state before seizing again is in status epilepticus and needs to be treated accordingly. When a hospitalized patient seizes, a fingerstick glucose should always be obtained, as hypoglycemia is a common cause of seizures in hospital patients. Glucose and thiamine should be given if the patient is hypoglycemic. Initial clinical assessment of a patient in status epilepticus includes neurological assessment, general evaluation with attention paid to respiratory and circulatory status, frequent vital signs, placement of two IV catheters, and cardiac monitoring with pulse oximetry. Patients should be given oxygen as needed. Electrolytes, glucose, toxicology, CBC, liver function tests, calcium, magnesium, arterial blood gas, and seizure medication therapeutic levels should be checked.

true The patient is suffering from status epilepticus. Status epilepticus refers to an epileptic seizure that lasts more than 5 minutes or a constant or near-constant state of having seizures. Initial therapy for status epilepticus should include a benzodiazepine medication such as lorazepam. Alternative medications would include diazepam or midazolam.

Bottom Line: Begin treatment of reflux in infants with conservative therapy, such as formula thickening.COMBANK Insight : Some questions on COMLEX will not be in the typical review books. When you come to a question that deals with something you are not familiar with, just pick an answer and move on. Remember, you are probably not the only one who does not know the correct answer.

true This infant is demonstrating signs of GERD and treatment should initially consist of conservative measures. Formula thickening with a SMALL amount of baby cereal and upright positioning following meals is recommended to prevent regurgitation and to promote digestion.

The superior and inferior labial arteries lay in close proximity to the oral mucosa. After an oral electrical burn, the patient tends to have perioral swelling secondary to acute tissue injury. One to 3 weeks after the initial injury, the necrotic tissue sloughs, potentially leading to exposure and injury to the labial artery. Labial artery bleeding is seen within this time frame, and patients should be made aware of this possible complication. Initial presentations may underestimate the extent of the ultimate injury, and patients require aggressive airway management.

true The superior and inferior labial arteries lay in close proximity to the oral mucosa. After an oral electrical burn, the patient tends to have perioral swelling secondary to acute tissue injury. One to 3 weeks after the initial injury, the necrotic tissue sloughs, potentially leading to exposure and injury to the labial artery. Labial artery bleeding is seen within this time frame, and patients should be made aware of this possible complication. Initial presentations may underestimate the extent of the ultimate injury, and patients require aggressive airway management.Answer A: If the patient received enough of an electrical injury to cause airway compromise, this would occur immediately after the burn and not as a delayed finding. Chest wall muscle paralysis from tetanic contraction may cause respiratory arrest if the current pathway is over the thorax. Injury to the respiratory control center of the brain can also cause respiratory arrest. The lungs are a poor conductor of electricity and generally are not as susceptible to direct injury from current as tissues with lower resistance.Answer B: The facial artery does not lie in as close proximity to the oral mucosa as the labial artery. Thus, it is not as commonly affected in electrical burns to the mouth. Life-threatening bleeding can occur 2 to 3 weeks after injury if the labial artery is exposed when the eschar falls off. Initial presentations may underestimate the extent of the ultimate injury; patients require aggressive airway management.Answer D: Recurrent epistaxis may be seen as a result of trauma or other injury caused by severe electrical burns but is not a common result of minor electrical burns to the mouth.Answer E: Ventricular tachycardia can be a complication of electrical injuries. However, dysrhythmias tend to present immediately after the electrical exposure and are not commonly seen as a delayed complication. One study identified 3 cases of delayed ventricular arrhythmias up to 12 hours after the incident. Other studies have shown no risk of delayed arrhythmias in patients with initially normal ECGs, both in low-voltage household exposures and after conducted electrical weapon exposure. Long-term cardiac complications from electrical injury are rare.

Panic disorder is commonly associated with agoraphobia, which is a fear of places from which it is difficult to escape.

true The woman most likely has panic disorder and is experiencing a panic attack. To meet the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for panic disorder, panic attacks must be associated with longer than 1 month of (1) subsequent persistent worry about having another attack or consequences of the attack, or (2) significant maladaptive behavioral changes related to the attack. To make the diagnosis of panic disorder, panic attacks cannot directly or physiologically result from substance use (intoxication or withdrawal), medical conditions, or another psychiatric disorder. Other symptoms or signs may include headache, cold hands, diarrhea, insomnia, fatigue, intrusive thoughts, and ruminations. Following exclusion of somatic disease, substance use disorders, and other psychiatric disorders, confirmation of the diagnosis of panic disorder with a brief mental status screening examination and initiation of appropriate treatment and referral are time and cost effective in patients with this condition, who have high rates of medical resource use. Some people with panic disorder avoid situations or places in which they have previously had a panic attack because they are afraid of it happening again. These people have agoraphobia, and they typically avoid public places where they feel immediate escape might be difficult, such as shopping malls, public transportation, or large sports arenas. About 1 in 3 people with panic disorder develop agoraphobia. Their world may become smaller as they are constantly on guard, waiting for the next panic attack. Some people develop a fixed route or territory, and it may become impossible for them to travel beyond their safety zones without suffering severe anxiety.

Bottom Line: Fluconazole is the drug of choice for empirical therapy for odynophagia in AIDS patients and can be used even if there is no evidence of oral thrush. If there is no improvement, EGD is needed for diagnosis.COMBANK Insight : Infectious esophagitis is primarily seen in patients who are immunocompromised. A history of immunosuppression: steroid therapy (including inhaled steroids), recent antibiotic use, or systemic illness supports the diagnosis.

true There are multiple causes of odynophagia (painful swallowing) and dysphagia (difficulty swallowing). In general, most causes of odynophagia with dysphagia are infections (most commonly Candida esophagitis) in patients with a history of immune suppression or cancer. A common cause of odynophagia in patients without a history of immune suppression would be medication-induced or pill esophagitis. Other infectious causes to consider would be Herpes simplex virus (HSV), Cytomegalovirus (CMV), and atypical organisms such as Mycobacterium. Rarely, patients with gastroesophageal reflux disease (GERD) can report severe odynophagia and dysphagia. This patient is presenting with a classic presentation for oropharyngeal and esophageal candidiasis. She has classic white plaques over the tongue and roof of her mouth, which scrape off with a tongue depressor. Given this, there should be a high level of concern for Candida esophagitis. Even without oral thrush, patients with human immunodeficiency virus (HIV) can be empirically treated for Candida esophagitis (before any further workup is needed) if odynophagia and dysphagia are present. This is because this is the most common cause of this complaint in HIV-infected patients with low CD4 counts and often resolves with empiric treatment. If the patient fails to improve with empiric treatment (usually should improve in 5-7 days), then EGD would be needed for diagnosis of alternative etiologies. Systemic treatment is needed for Candida esophagitis, and the preferred drug regimen is 14-21 days of oral fluconazole. While oral nystatin can be used to treat thrush, it would be insufficient for the treatment of esophagitis due to the inability to penetrate all the esophageal folds, leading to continued infection or relapse.

Bottom Line: Ticks should be removed with fine-tipped tweezers by grasping the tick close the skin's surface and pulling upwards. Afterwards, the area should be cleaned with alcohol or soap and water. COMBANK Insight : The primary risk factor for developing cutaneous manifestations of Lyme disease is exposure to Ixodes (deer) ticks (from areas likely to harbor ticks, such as woody, brushy, or grassy outdoor habitats), which transmit B burgdorferi from host to host.

true There are several tick removal devices on the market, but a plain set of fine-tipped tweezers will remove a tick quite effectively. Use tweezers to grasp the tick as close to the skin as possible and pull upward with steady pressure. If the mouth-parts break off in the skin, they can be removed with tweezers. After the tick is removed, clean the skin with soap and water. The live tick can be flushed down the toilet, placed in a bag, or sealed in tape and thrown in the trash. The goal is to remove the tick as quickly as possible--not waiting for it to detach as the chances of infection transmission are directly related to the time the tick is attached. In general, the tick must be attached for 36-48 hours before infection can be transmitted.

The first-line treatment for insomnia is behavioral therapy. When behavioral therapy fails, the first and safest medication to try is a melatonin agonist, or ramelteon. Benzodiazepines and Z-drugs have been shown to be effective but have significant abuse potential and side effects and should be avoided in patients with comorbid substance abuse disorders.

true This patient has increased sleep latency with a comorbid substance abuse disorder and may benefit from melatonin or a melatonin receptor agonist such as ramelteon. Ramelteon is approved for the treatment of insomnia characterized by difficulty with sleep onset. It does not have an affinity for GABA receptors, which removes the potential for abuse, making it safer than the benzodiazepine and z-drugs (non-benzodiazepines). Studies have shown that ramelteon is effective in reducing bothpolysomnographic and subjective sleep latency in patients with chronic insomnia. The most common side effects include dizziness, nausea, and fatigue.

Bottom Line: Myxedema coma is hypothyroidism so severe that it results in hypothermia, hypotension, hypoventilation, and altered mental status. Bottom Line: Treat myxedema coma with intravenous (IV) thyroxine and hydrocortisone (or other glucocorticoid), and seriously consider IV triiodothyronine. In myxedema coma, the treatment of choice is 5 to 8 μg/kg of thyroxine (T4) and then 50 to 100 μg intravenously (IV) daily. Because peripheral conversion of T4 to triiodothyronine (T3) is often impaired, you may also opt to give 5 to 10 μg of T3 every 8 hours, although proceed with caution because T3 is more arrhythmogenic. You MUST also give adrenal replacement empirically because there are typically decreased adrenal reserves in myxedema coma.

true This is an example of the most severe presentation of hypothyroidism. Early manifestations of hypothyroidism include depression, cold intolerance, fatigue, constipation, menorrhagia, coarse/brittle hair and nails, delayed deep tendon reflexes, hypertension, and hyperlipidemia, among many others. Later on, patients exhibit symptoms such as slow speech, hoarseness, loss of the lateral one-third of the eyebrow, myxedema (nonpitting skin thickening due to increased glycosaminoglycans), bradycardia, and effusions. Myxedema coma is hypothyroidism so severe that it results in hypothermia, hypotension, hypoventilation, and altered mental status. Greater than 90% of primary hypothyroidism is due to Hashimoto thyroiditis, which causes patchy lymphocytic infiltration of the thyroid. This typically presents in 20- to 60-year-old women, and there is an increased association with other autoimmune disorders. Most of these patients will be positive for antithyroid peroxidase and antithyroglobulin antibodies. Other primary causes of hypothyroid include iatrogenic, amiodarone, and lithium. Secondary causes are hypothalamic or pituitary failure. Free thyroxine will be decreased in all cases, and typically, thyroid-stimulating hormone will be elevated in primary causes and decreased in secondary causes. The patient in the question stem presents with a history consistent with the early and later manifestations of hypothyroidism. In the emergency department, her vitals show hypotension, hypothermia, bradycardia, hypoventilation, and altered mental status.

Bottom Line: Congenital diaphragmatic hernia presents with severe respiratory distress in the first 24 hours of life and is associated with lung hypoplasia.COMBANK Insight : Review the osteopathic findings for clues about disease localization, pathology, and chronicity.

true This neonate most likely has a congenital diaphragmatic hernia. This usually presents with severe respiratory distress in the first 24 hours of life and is associated with lung hypoplasia. This condition carries a high mortality rate and should be surgically corrected as soon as possible. Viscerosomatic reflexes are a type of somatic dysfunction caused by changes in the autonomic nervous system. They can be acute or chronic and are considered to be a somatic representation of visceral disease. When either branch of the autonomic nervous system (sympathetic or parasympathetic) overstimulates a particular organ, a reflex reaction occurs. The soma at the same level of the organ's autonomic innervation takes on characteristics of somatic dysfunction (TART). T2-T7 is where the sympathetic viscerosomatic reflex for the pulmonary system is located.

Bottom Line: Carpal tunnel syndrome may be part of the presentation with amyloidosis. Approximately 20% of patients with L chain-type amyloidosis initially report weakness and paresthesia of one or both hands, suggesting carpal ligament involvement.

true This patient exhibits signs and symptoms consistent with amyloidosis, including waxy skin deposition, carpal tunnel, new cardiac symptoms (S3 and lower extremity edema), and the nonspecific symptoms of fatigue and weight loss. The most common presenting symptoms of immunoglobulin-related amyloidosis (weakness and weight loss followed by purpura, particularly around the eyes) are nonspecific. Other symptoms and physical findings vary widely, depending on which organs contain deposits. Amyloid deposition in a particular organ leads to similar clinical consequences and, therefore, similar complaints, regardless of the type of amyloid deposited. For example, cardiac L chain-type amyloidosis and cardiac TTR amyloidosis cause similar symptoms. Peripheral neuropathy may also occur. Patients whose disease involves the peripheral nerves often report dysesthesia, decreased sensation, and decreased strength. Symptoms usually affect the lower extremities more severely than the upper extremities. Carpal tunnel syndrome may be part of the presentation. Approximately 20% of patients with L chain-type amyloidosis initially report weakness and paresthesia of one or both hands, suggesting carpal ligament involvement.

An overdose of tricyclic antidepressants such as amitriptyline may cause prolongation of the QT interval and widened QRS complexes as well as signs of cholinergic toxicity such as fever, dilated pupils, and flushing.

true This patient has a history of depression, which is commonly treated with either a serotonin reuptake inhibitor (SSRI) or tricyclic antidepressant (TCA). While the most common side effects of TCAs such as amitriptyline (A) are urinary retention, dry mouth and constipation, they are also known to cause delirium along with cardiac arrhythmia. Overdose can occur with ingestion of as little as 10 times the normal daily dose. TCA medications have anticholingeric side effects, and so symptoms of an overdose may include hyperthermia, dilated pupils, and facial flushing. Overdose may also cause cardiac abnormalities. Signs of cardiotoxicity include prolongation of the QRS > 100 msec, abnormal morphology of the QRS (eg, deep, slurred S wave in leads I and AVL), and abnormal size and ratio of the R and S waves in lead AVR (R wave in AVR >3 mm; R to S ratio in AVR > 0.7).

Bottom Line: A benzodiazepine such as lorazepam is the drug of choice in the treatment of alcohol withdrawal syndrome in patients with liver disease.

true This patient has alcohol withdrawal syndrome as evidenced by his tremors, diaphoresis, hypertension, nausea, and hallucinations. He may even already be progressing to delirium tremens (DT), which is a life-threatening complication of alcohol withdrawal. The drug of choice to control the symptoms is a benzodiazepine. Lorazepam is preferred in patients with liver disease because of its short half-life and decreased risk of oversedation. Other medications such as haloperidol may be indicated to control agitation in these patients if needed, although primary control of the withdrawal syndrome should be attempted first with benzodiazepines. The diagnostic criteria of alcohol withdrawal syndrome include the following: A. Cessation of (or reduction in) alcohol use that has been heavy and prolonged. B. Two (or more) of the following, developing within several hours to a few days after criterion A: 1. Autonomic hyperactivity (eg, sweating or pulse >100/min) 2. Increased hand tremor 3. Insomnia 4. Nausea or vomiting 5. Transient visual, tactile, or auditory hallucinations or illusions 6. Psychomotor agitation 7. Anxiety 8. Grand mal seizures C. The symptoms in criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.

COMBANK Insight : Two basic principles underlie the management of patients with malabsorption, as follows: (1) the correction of nutritional deficiencies, and (2) when possible, the treatment of causative diseases.

true Think of malabsorption syndrome as a potential cause of iron-deficiency anemia when a history of "fatty stools" is present.

Courvoisier sign is a palpable gallbladder on physical exam, usually associated with biliary or pancreatic malignancy. Suspect malignancy in a patient with obstructive jaundice, weight loss, and a history of smoking.

true This patient has obstructive jaundice, which is a harbinger for underlying biliary or pancreatic malignancy. Jaundice is usually present when bilirubin levels are greater than 2.5 to 3 mg/dL. Weight loss, abdominal pain, and anemia (most likely anemia of chronic disease) are other clues to this diagnosis. There is a strong correlation between smoking and pancreatic malignancies. Pruritus results from the deposition of bile acids in the skin. Physical exam can reveal a "palpable gallbladder" (which presents as an elongated, smooth, nontender mass, normal in contour, and slightly mobile, that may extend to the patient's umbilicus or even below it). This is known as Courvoisier sign.

Bottom Line: TSH should be included in the initial work-up of patients demonstrating signs and symptoms of hypothyroidism.COMBANK Insight : If TSH levels are above the reference range, the next step would be to measure total T4 with a measure of binding proteins. Thyroxine is highly protein bound (99.97%) with approximately 85% bound to thyroid-binding globulin (TBG), approximately 10% bound to transthyretin or thyroid-binding prealbumin, and the remainder bound loosely to albumin.

true This patient is demonstrating signs and symptoms of hypothyroidism, which is most commonly caused by autoimmune processes in female adults. When hypothyroidism is suspected, you should begin the work-up by ordering an initial TSH level. Osteopathic pearl: A Chapman point represents the somatic manifestation of a visceral dysfunction. The anterior Chapman reflex point related to the thyroid is located at the 2nd intercostal space along the sternal border. The posterior Chapman reflex point related to the thyroid is located at the T2 transverse process. Once a Chapman point is localized, firm pressure is applied to the point. Pressure is applied in a circular pattern with the attempt to flatten the mass, and is continued until the lesion is resolved or the patient can no longer tolerate treatment.

Ankylosing spondylitis commonly presents in young males with chronic back stiffness, photosensitivity, oral ulcerations, and fatigue. The pain from inflammatory arthritis improves with exercise and movement.

true This patient is demonstrating symptoms most consistent with ankylosing spondylitis, which is a chronic and painful type of inflammatory, degenerative arthritis that eventually results in rigidity of the spine, known as "bamboo spine." Ankylosing spondylitis most commonly presents in young males (age 15-30) who have chronic pain and stiffness in the lumbar spine. This pain characteristically improves with movement and exercise, which is common with inflammatory arthritis. Spinal stiffness, immobility, and postural changes, especially hyperkyphosis, are also commonly seen. The patient's eye pain and irritation are likely secondary to uveitis. The frequency of uveitis in patients with ankylosing spondylitis is approximately 25% to 35%. Radiographs of the spine may reveal pseudo-widening, erosions, and sclerosis of the sacroiliac joint, in addition to the classic "bamboo spine" changes. An early sign is "squaring" of the vertebral bodies, best seen on lateral x-ray. HLA-B27 is associated with ankylosing spondylitis but is not diagnostic and should only be used with caution.

Bottom Line: After lorazepam, phenytoin or fosphenytoin is the next treatment of continued seizure.COMBANK Insight : On the COMLEX, the initial medication of choice for treatment of any seizure is lorazepam/diazepam/midazolam, followed by phenytoin or fosphenytoin. Levetiracetam is also an option; however, COMLEX is not always up to date with current medical literature. If the patient continues to seize and appears to be in status, you would likely need to intubate and then start a propofol/versed/pentobarbital drip. Keep in mind that current clinical practice is not always on the boards, so study the books, not the latest treatment modalities you learn on your rotations.

true This patient is in status epilepticus, not because of the length of the first seizure, but because he has had 2 seizures without return to baseline in between. Treatment of status epilepticus in real life may differ from what is tested on the boards. Most of the time the order of progression will begin with lorazepam, then phenytoin, then phenobarbital, then propofol with patient intubated.

Bottom Line: Spinal cord tumors typically present with gradually worsening back pain with sudden onset of spinal cord dysfunction.COMBANK Insight : In scenarios like these, it may be easier to eliminate answers that do not fit the description instead of trying to determine the exact cause of disease. These questions may be intentionally vague and may not include the "classic" presentation of disease; however, the description includes symptoms that would almost never fit the other answer choices.

true This patient is most likely suffering from spinal cord compression as a result of a growing tumor. The typical presentation is gradually worsening back pain with insidious onset of spinal cord dysfunction. Spinal dysfunction can lead to a variety of complaints depending on where in the cord the tumor is located and how large the tumor is. It can cause urinary incontinence with bowel dysfunction if it is located in the lower spinal cord whereas it will cause muscle weakness if it compresses nerves of the brachial plexus. Spinal cord tumors may be diagnosed with computed tomography but are best evaluated with magnetic resonance scanning. The most common tumors of the spinal cord are metastatic disease, ependymomas, and astrocytomas. Meningiomas are common intraspinal extramedullary tumors.

This patient has left serous otitis media which can be a complication of recurrent episodes of acute otitis media. The diagnosis is made by observing air bubbles and fluid behind the tympanic membrane. The lateralization, or Weber, test showed louder vibration on the left indicating conductive hearing loss on the left. In conductive hearing loss, sound will be detected longer in the bone on the affected side. Treatment is supportive, and myringotomy can be considered. The Weber test is a quick screening test for hearing. It can detect unilateral middle ear hearing loss and unilateral inner ear hearing loss. A normal Weber test has a patient reporting the sound heard equally on both sides. In an affected patient, if the defective ear hears the Weber tuning fork louder, the finding indicates a conductive hearing loss in the defective ear. In an affected patient, if the normal ear hears the tuning fork sound better, there is sensorineural hearing loss on the other (defective) ear. The Rinne hearing test is based on the acoustic phenomenon that air conduction of sound should be greater than bone conduction. To test this, place the vibrating tuning fork on the patient's mastoid process and ask the patient to tell you when the sound disappears. As soon as the patient answers, shift the tuning fork to the external auditory canal with both tines pointing toward the ear for maximum vibration; then ask if the patient can hear the sound now. If the patient responds, then the test is normal. Not hearing the sound return suggests a conduction hearing loss on that side. If the patient has heard sound in both locations, you might want to ask which place is louder. Obviously, for normal hearing, the sound at the auditory canal should be louder than at the mastoid.

true This patient presents with serous otitis media without evidence of an active infection. This condition and its associated hearing loss will usually self-resolve in a few weeks, especially in otherwise healthy children. The child should be followed clinically without the administration of antibiotics.

The extensor carpi ulnaris tendon is in the sixth compartment of the wrist and is responsible for snapping over the -----

ulnar styloid.

Bottom Line: Subclinical hyperthyroidism in elderly presents with fatigue and insomnia and can lead to atrial fibrillation. Checking a TSH level can lead you to the diagnosis.

true This patient is presenting with atrial fibrillation (AF) from hyperthyroidism. The subtle, "apathetic presentation" with few symptoms, as described in this case (i.e., fatigue, insomnia, irregular pulse), can be seen in elderly individuals with hyperthyroidism. The electrocardiogram pattern is also diagnostic for atrial fibrillation (irregularly irregular rhythm with absent P waves). In contrast, younger patients with hyperthyroidism and those with comorbidities can present with myriad nonspecific symptoms, including acropachy, fatigue, hypertension, and increased appetite.The most common endogenous cause of subclinical hyperthyroidism (~60% of patients) is a multinodular goiter. Subclinical hyperthyroidism carries significant health risks, and yet the evidence is lacking on when to treat this condition. Prolonged subclinical hyperthyroidism can lead to atrial fibrillation and to systolic and diastolic cardiac dysfunction. Subclinical hyperthyroidism is also associated with decreased bone density and an increased risk of dementia. Rely on second- or third-generation TSH screening (normal = 0.5-5 mIU/L), which is more sensitive and specific than measuring free T4 (thyroxine) alone. Older patients usually have a higher normal TSH level. In one study, 70% of patients > 80 years had a TSH > 4.5 mIU/L. If the TSH level is low (< 0.5 mIU/L), measure free T3 (triiodothyronine) and free T4 levels, which are elevated in hyperthyroidism and normal in subclinical hyperthyroidism.Treatment consists of symptomatic relief with beta blockers and medical therapy directed at the increased thyroid hormone levels. These medications include propylthiouracil, methimazole, and nuclear medicine ablative therapy.

Bottom Line: Infectious biliary pathology, including cholecystitis and cholangitis, is often secondary to ascending enteric organisms. Antibiotics coverage must empirically cover gram-negative organisms, including Escherichia coli, and may require coverage for mixed anaerobes and gram-positive organisms as well.

true This patient is presenting with community-acquired cholangitis. This is a bacterial infection of the bile duct system most commonly associated with ascending organisms from the duodenum secondary to biliary obstruction. The most common organism associated with infection is Escherichia coli. Other causative organisms include Klebsiella, Enterobacter, and mixed anaerobe species. The most common gram-positive pathogen is Enterococcus. However, the Infectious Diseases Society of America (IDSA) guidelines state that in a patient with community-acquired cholangitis, coverage for enterococci is not required.Because this patient's disease severity cannot be stratified due to lack of lab data, empiric coverage must include appropriate enteric organisms. Of the answer choices listed, only piperacillin-tazobactam has comprehensive coverage for enteric organisms. Metronidazole may be added as complimentary therapy in patients treated with a medication such as ciprofloxacin or ceftriaxone because these medications do not have anaerobic coverage. The IDSA does endorse its use in community-acquired disease only if there are severe patient comorbidities. In the absence of clinical deterioration or culture results, a trial of empiric antibiotics for 24 to 48 hours can occur prior to adding or changing therapy.

Bottom Line: Primary Epstein-Barr Virus infection can be asymptomatic in children but in older patients tends to present with a triad of fever, rash, and cervical lymphadenopathy.

true This patient is presenting with infectious mononucleosis (MI), which is a clinical syndrome of primary infection with the Epstein-Barr virus (EBV). Over 90% of the world's population is infected with EBV, but primary infection is only symptomatic in some people. Transmission typically occurs through saliva (i.e. "Kissing Disease"). The risk of developing symptoms at the time of primary infection increases with age. Primary infection that occurs in infancy or early childhood is often asymptomatic. Primary infection that occurs in adolescence or early adulthood leads to IM in about 30%-77% of patients. The classic triad presentation of IM includes: fever, pharyngitis, and lymphadenopathy of the posterior cervical chain. Other findings that support the diagnosis of IM include:fatigue/malaise, splenomegaly, and lymphocytosis which may be > 50% atypical lymphocytes (e.g. large, irregularly shaped, reactive lymphocytes) on a peripheral blood smear. Management of this syndrome is primarily supportive and activity restriction for a minimum of three weeks to avoid splenic rupture (e.g. no contact sports) is recommended. A full recovery is expected in 2-3 months.

Constitutional symptoms are an important part of the review of systems (ROS) for almost any medical patient. In the setting of diabetes unexplained weight loss as well as fatigue/malaise/lethargy could be due to poor glycemic control. This patient could be undergoing hypoglycemic or hyperglycemic episodes, and symptoms of both should be addressed, including level of consciousness, sweats, dizziness, and lightheadedness for hypoglycemia and polydipsia, polyurea, and frequent urination for hyperglycemia. An opthalmologic ROS is important to assess for worsening vision and eye changes that can be associated with diabetic retinopathy, specifically asking about visual changes, eye pain, double vision, scotomas, floaters or the sensation of amaurosis fugax.This patient should be asked about his cardiovascular system due to his diabetes. He should be asked specifically about chest pain, shortness of breath, exercise intolerance, orthopnea, edema, palpitations, faintness, loss of consciousness, and claudication. Because shortness of breath can be included under the cardiovascular system as an anginal equivalent, you could consider that the respiratory ROS has been partially performed as well, though there is no specific requirement to ask about cough, sputum production, or wheezing in a patient without lung pathology. A urinary ROS can assess for possible hyperglycemia, which can also predispose a patients to more frequent urinary tract infections. It would be prudent to ask specifically about dysuria and polyuria.An ROS that incorporates both skin and the nervous system is important as the feet are a common site of development of neuropathy, diabetic ulcers, and skin breakdown. A good skin review of systems should include inquiring about rashes, lesions, wounds, nodules, and excessive dryness and/or discoloration.A psychiatric ROS should be performed in any patient with chronic disease as depression is more common in patients with chronic conditions and is a serious illness which can impact adherence to therapy and overall wellbeing.

true This patient is suffering from milk-alkali syndrome, also known as Burnett's syndrome, which is characterized by hypercalcemia caused by repeated ingestion of calcium and absorbable alkali. In the above scenario, the patient's hypercalcemia is most a result of excessive treatment with calcium carbonate. Signs of hypercalcemia include nausea and vomiting, lethargy, altered mental status, depression, fatigue, and acute dysrhythmias. Effects secondary to hypercalcemia can be remembered by the mnemonic bones, stones, groans, and psychiatric undertones, which refers to nephrolithiasis, bone pain, anorexia, vomiting, constipation, and mental status changes. Because trans-membrane potentials are altered in hypercalcemia, QT interval shortening is often seen, along with PR interval prolongation.

Bottom Line: A wide splitting second heart sound with respiratory variation may be associated with pulmonic stenosis or a right bundle branch block. Fixed splitting of the second heart sound is heard in atrial septal defect. Paradoxical splitting can be due to left bundle branch block or aortic stenosis.COMBANK Insight : Physiology is very important for Step 3 exams. Make sure you are aware of WHY you get certain physical exam signs. Understand how respiratory variation and other maneuvers affect right ventricular preload and how that can change heart sounds.

true This patient likely has a right bundle branch block (RBBB) causing a widely split second heart sound. The second heart sound is produced by the closure of the aortic and pulmonic valves, and the sounds they produce are often called A2 and P2. Generally, A2 is louder and is the main component of the S2 heart sound. In general, the aortic valve closes slightly earlier than the pulmonic valve, although in many cases, that separation cannot be auscultated. When these sounds are temporally separated, however, they can be distinguished as separate and generate numerous possible combinations. The most common is the physiologic split S2 where inspiration causes increased venous return to the right heart and slows closure of the pulmonic valve and delays P2. This is best heard at the pulmonic listening post because P2 is the softer sound. In the case above, there is always delayed closure of the pulmonic valve due to the RBBB. Because impulses from the atrioventricular (AV) node must travel down the left bundle and across the left ventricle to reach the right ventricle, the left ventricle will always empty its blood faster than the right ventricle, and the aortic valve will always close long before the pulmonic valve, generating a constant splitting sound. However, in inspiration, there is an increased venous return to the right heart. Therefore, the split will be accentuated with inhalation. This is different from a fixed split, in that although the widened split is present throughout the respiratory and cardiac cycle, it changes with inspiration and becomes wider. A fixed split does not change. The common causes of a widened split S2 include pulmonic stenosis and RBBB. Note the diagram below in which the A2 and P2 heart sounds are denoted by blue and purple lines, respectively:

When results of ultrasound are equivocal or negative for cholecystitis, cholescintigraphy (HIDA scan) is indicated in the presence of high clinical suspicion.

true This patient presents with the classic symptoms of acute cholecystitis. Right upper quadrant abdominal pain, fever, and leukocytosis suggest the diagnosis. A physical examination may reveal a Murphy sign (inspiratory arrest upon deep palpation of the right upper quadrant). Laboratory results generally show an elevated white blood cell count. Alkaline phosphatase and bilirubin are typically normal. The initial imaging modality of choice is an ultrasound because it is a rapid, safe, and cost-effective test. The sensitivity of ultrasound approaches 95%. When results of ultrasound are equivocal or negative for cholecystitis, cholescintigraphy (HIDA scan) is indicated in the presence of high clinical suspicion. Cholescintigraphy is a nuclear imaging procedure where a radioactive tracer, technetium-99m, is injected intravascularly. The tracer circulates to the liver and is excreted into the biliary system, and the flow of bile into the common bile duct, cystic duct, and gallbladder is studied. A normal study would reveal visualization of the gallbladder that fills with tracer material. A positive study that would support acute cholecystitis has no isotope accumulation visualized in the gallbladder, indicating an obstruction of the cystic duct. False positives may be seen in situations of severe liver disease, in patients on total parenteral nutrition, and in patients with hyperbilirubinemia or alcohol or opiate abuse. Cholescintigraphy has a sensitivity and specificity of approximately 95%. The negative predictive value of a normal exam in excluding acute cholecystitis is greater than 99%.

Bottom Line: A cytology report of atypical squamous cells of undetermined significance should be followed up with a human papillomavirus screen or repeat Pap smear in 1 year. If the screen is positive or the cytology at 1 year is abnormal, the patient should get a colposcopy.

true This patient's Pap smear result was atypical squamous cells of undetermined significance (ASCUS). This means that the cells are not normal, but the significance of the atypia has not be determined. According to the American Society for Colposcopy and Cervical Pathology guidelines, there are 2 options after ASCUS results: a repeat Pap smear in 1 year or human papillomavirus (HPV) testing. In the 25- to 29-year-old age group, the preferred option is HPV testing. If the HPV test is positive, then the patient should undergo colposcopy. If the HPV is negative, then the patient should have repeat cotesting with cervical cytology and HPV testing in 3 years. If the option was chosen to repeat the Pap in 1 year and the repeat Pap is normal, then the patient can resume normal testing. If the repeat Pap is abnormal (ASCUS or any other worse pathology), then the patient should undergo colposcopy. If the patient was in the 21- to 24-year-old age group, then the guidelines give the same 2 options of repeat testing in 1 year or HPV testing. However, in this age group, the repeat testing in 1 year is the preferred method. After age 30, routine screening involves cotesting (Pap and HPV test every 5 years) or Pap alone every 3 years. The same guidelines apply as for the 25- to 29-year-old age group for ASCUS pathology.

Bottom Line: Slipped capital femoral epiphysis is a disease of the proximal femoral growth plate which causes the femoral head to be displaced posteriorly and inferiorly with hip and knee pain as the most common presenting symptom. Initial diagnostic tool is a plain radiograph. Slipped capital femoral epiphysis (SCFE) is associated with avascular necrosis of the femoral head. Slippage of the femoral head causes compromise to the vascular supply. Necrosis occurs at a rate of 7.5% within the first 24 hours. It increases to greater than 75% after 48 hours. Therefore, consultation with an orthopedic surgeon is emergent.

true This patient's clinical presentation is consistent with slipped capital femoral epiphysis (SCFE). SCFE is a rare disease in which there is instability at the proximal femoral growth plate, causing the femoral head to be displaced posteriorly and inferiorly. An x-ray of the hip is the most appropriate first step in diagnosis. In this case, the patient presented with knee pain also. Thus, an x-ray of the knee would be appropriate. SCFE commonly occurs in children age 10 to 16 years and is twice as common in boys than in girls. It has a high predominance in obese children. Treatment includes surgical pinning of the femoral head.

Parallel group trials have 2 or more different groups of patients who receive different treatments in parallel. Crossover trials have 1 group of patients who each receive different treatments in serial.

true This question asks about a double-blinded, parallel group, stratified, randomized trial. To get the answer, you need to understand what each of those descriptors means.In double-blinded studies, both patients and providers are blind to the treatment. In this study, the intravenous (IV) fluid was put into identical bags, and neither the doctors nor the patients knew what kind was given.Parallel group trials occur when each group of patients gets a different treatment. This is in contrast to crossover trials, where one group of patients would receive treatment A first, and then later get treatment B. In a parallel design, you need a larger sample size and you worry about differences between the 2 groups. In a crossover design, each patient serves as his or her own control. The study lasts longer but can use a smaller sample size, but this design only works in chronic, stable patients who will need treatment over a long period, and where the treatment effect is short-lived.Stratification means that patients are divided into groups based on specific important characteristics. In the SAFE trial, patients were stratified based on trauma. The 2 groups (trauma and no trauma) are then separately randomized. This guarantees that each arm of the study will have equal numbers of patients with that variable of interest.Randomization means that each patient is randomly assigned to a treatment group. Essentially, with each new patient enrolled, a coin is flipped to decide treatment A versus B. In this way, on average, 50% of patients will wind up in each arm, but in reality, the numbers will be slightly off, just as if you flipped a coin 100 times and got 48 heads and 52 tails.

Bottom Line: Treatment of Wolff-Parkinson-White syndrome may consist of carotid massage, the Valsalva maneuver, procainamide, and cardioversion if the patient is unstable.

true Treatment may also consist of class IA or class III antiarrhythmics. Digoxin, β-blockers, and calcium channel blockers should be avoided because these medications may block the AV node further, thereby increasing the risk of developing re-entry leading to supraventricular tachycardia. Amiodarone can slow conduction through the accessory pathway with chronic administration but has not been shown to do this during acute administration. Therefore, amiodarone is also generally avoided in the acute setting because it does have a propensity to slow AV conduction.Some of the class IC antiarrhythmics such as flecainide and propafenone can also be used to treat WPW but are not available in intravenous formulations in the United States. These medications are generally now the drugs of choice given their favorable risk-benefit profile for the long-term treatment of AVRT if medical therapy is required.

The most likely diagnosis in this patient is a deep venous thrombosis (DVT). The key to answering this question is knowing both the timeline for common causes of postoperative fever and incorporating important physical examination findings. It is important to know that postoperative DVT is very common. Some studies have shown that in patients without prophylaxis (typically Aspirin), up to 80% of orthopedic surgical patients will develop a DVT.Postoperative days 1-2: Atelectasis/pneumoniaPostoperative days 3-5: Urinary tract infectionPostoperative days 4-6: DVT or pulmonary embolismPostoperative days 5-7: Surgical site infectionPostoperative days 7+: MedicationThe 5 W's can help with memorization: wind, water, walking, wound, and wonder drugs.Duplex ultrasound of the lower extremity is the best initial test. It is cheap and noninvasive. Signs of lower extremity DVT include erythema, swelling, and pain on dorsiflexion of the foot.

true This ultrasound image shows an obvious hyperechoic filling defect within the left common femoral vein. Other ultrasound finding include noncompressibility and lack of flow on color Doppler.Patrick's (FABER) test is used to assess pathology of the sacroiliac and hip joint, especially osteoarthritis of the hip. The term FABER actually indicates the positioning of the hip being tested: flexion, abduction, external rotation, and then extension. The patient's hip is flexed, abducted, and externally rotated into a figure 4 position. Any pain in or around the hip joint indicates generally pathology of the hip joint. At this point, the physician places one hand on the contralateral anterior superior iliac spine and the other hand on the knee of the testing leg. Pressure is placed downward on both points, with the most important motion being the further extension of the hip. Pain will be accentuated by any arthritic changes in the hip or sacroiliac joint.

ottom Line: Letrozole, an aromatase inhibitor is now considered first-line therapy for ovulation induction in patients with polycystic ovarian syndrome (PCOS).

true This woman has features of polycystic ovarian syndrome (PCOS), including irregular menstrual cycles or amenorrhea, hirsutism, and acne and would benefit from the addition of letrozole. In order to diagnose PCOS, a patient must have two out of the following three criteria: the presence of oligoovulation or amenorrhea, clinical or biochemical evidence of elevated androgens, and polycystic ovaries, as evaluated by ultrasonography. Due to these patients having abnormal menstrual cycles, many of them will also have infertility. Letrozole, an aromatase inhibitor is now considered the drug of choice in ovulation induction in patients with PCOS. Current data also suggest that Letrozole is superior to clomiphene for live birth rates in oligoovulatory women with PCOS (patient in this vignette). Letrozole has other advantages over clomiphene including a higher rate of monofollicular development (reduced risk of multiple pregnancies), shorter half-life, and decreased antiestrogenic adverse effects on the endometrium.

The most likely diagnosis is polymyositis. Polymyositis is a progressive systemic connective tissue disorder characterized by immune-mediated muscle inflammation primarily affecting striated muscle fibers. It usually affects patients between the ages of 50-70 and affects females more than males. It may present symmetric progressive proximal muscle weakness, such as in the shoulder girdles and hips. Lab analysis reveals an increased serum creatinine kinase, increased aldolase, and positive anti-Jo-1 antibodies. Treatment consists of high dose corticosteroids. Dermatomyositis is a connective tissue disease similar to polymyositis in that it also often presents with proximal muscle weakness and systemic symptoms. In addition to these symptoms, skin findings are also present. These include the classic heliotrope rash (violaceous erythema of the eyelids), Gottron's papules overlying the joints of the fingers, shawl sign (violaceous erythema over the back of the neck and posterior shoulders), and "mechanic's hands," which refers to scaly fissures and inflammatory changes of the hands.

true To differentiate polymyositis/dermatomyositis from polymyalgia rheumatica (PMR), remember that PMR presents more commonly with proximal muscle pain, not weakness.

Some of the lowest risk factors for the development of pancreatic cancer are alcohol use (>4 drinks per day), BMI >30, diabetes mellitus >5 years, family history of pancreatic cancer in a first degree relative, and tobacco abuse. These increase the risk less than fivefold. Higher risk conditions include chronic pancreatitis and cystic fibrosis as well as having 2 or more first degree relatives with pancreatic cancer. The highest risk groups include patients with more than 3 relatives with pancreatic cancer, hereditary pancreatitis, and Peutz-Jeghers syndrome. Other hereditary conditions include multiple endocrine neoplasia, Lynch syndrome, and Von Hippel-Lindau among others. Peutz-Jeghers syndrome (PJS) is an autosomal dominant disorder associated with the development of hyperpigmented macules on the lips and oral mucosa as well as benign hamartomatous polyps throughout the GI tract. It is associated with a 10-15x increased risk of GI, lung, and gonadal malignancies and confers the highest increased risk of the factors listed above. Patients with PJS generally have a mutation in the STK11/LKB1 gene and molecular testing is available. Due to increased risk of cancer, these patients should have increased monitoring for malignancy.

true Tobacco abuse, alcohol abuse, and obesity are all risk factors for pancreatic cancer and increase the risk by less than 5 fold.

Neuroleptic malignant syndrome most commonly presents with markedly elevated levels (more than 1000 IU/L) of creatine kinase, making it a useful test to order in a patient with NMS. Muscle cell damage from severe muscle rigidity during an acute episode can result in elevated serum creatinine kinase. Additionally, the damaged muscle cells can also release myoglobin, resulting in myoglobinuria, and rhabdomyolysis.

true Treatment for neuroleptic malignant syndrome involves supportive care measures, dantrolene to control hyperthermia, and bromocriptine to reverse loss of dopaminergic tone. The treatment for neuroleptic malignant syndrome largely involves cessation of neuroleptic medications and supportive care measures such as IV fluids, antiarrhythmics to correct any potential arrhythmias that may arise from the syndrome, correction of electrolyte abnormalities, antihypertensive agents to correct malignant hypertension, and anticoagulation to prevent thrombosis. However, two agents that can be useful in the treatment of NMS are dantrolene and bromocriptine. Dantrolene is a muscle relaxant that is effective in relieving malignant hyperthermia. Bromocriptine is a dopamine agonist that is given to restore lost dopaminergic tone during NMS.

Bottom Line: In young women under the age of 30 with palpable breast masses, ---- is superior to mammogram as the initial testing modality.

ultrasound Ultrasound-guided core needle biopsy is the preferred method of tissue sampling for suspicious, palpable, breast masses.

Ulcerative colitis (UC) is an inflammatory gastrointestinal disease that exclusively affects the mucosal layer of the colon and rectal regions. The exact etiology of the disease is unknown; however, it is associated with the HLA-B27 antigen. Symptoms can range from mild, self-limiting episodes to severe exacerbations. They may include crampy abdominal pain, rectal bleeding, tenesmus, hematochezia, loose mucous-like stools, and fever. In the most severe presentation, the inflammation can extend to the muscular layers of the colon, resulting in colonic dilatation, which is commonly known as toxic megacolon. In addition, UC can present with extraintestinal manifestations. These include erythema nodosum (shown in the exhibit), uveitis, autoimmune hemolytic anemia, and sclerosing cholangitis. Patients with UC are at an increased risk for colon cancer than the rest of the population, which increases significantly seven to eight years after the onset of the disease.

true UC presents with episodes of crampy abdominal pain, rectal bleeding, tenesmus, and loose stools with mucus. The disease can have extraintestinal symptoms such as erythema nodosum, uveitis, autoimmune hemolytic anemia, and sclerosing cholangitis. It is associated with a higher risk of developing colon cancer. Patients with ulcerative colitis may show loss of normal vascular markings and increased friability of the colonic mucosa, along with exudates, pseudopolyps, petechia, and frank hemorrhage on colonoscopy. Patients with ulcerative colitis (UC) will present with numerous inflammatory findings on colonoscopy. For instance, vascular markings are lost due to engorgement of the mucosa, giving it an erythematous appearance. Other findings include the presence of petechiae, exudates, touch friability, and frank hemorrhage. More severe cases may be associated with profuse bleeding and copious exudates. Pseudopolyps occur as a reaction to prior inflammation and signify some degree of chronicity. Notably, the inflammatory findings occur in a continuous fashion, in contrast to Crohn disease, where inflammatory changes occur in a more patchy, segmented fashion.

Bottom Line: Acute pulmonary embolism will cause an increase in dead space, leading to impaired oxygenation and ventilation, in turn causing hyperventilation by the chemoreceptor centers in the brain. This mechanism will "blow off" more carbon dioxide than necessary, resulting in respiratory alkalosis.COMBANK Insight : A good grasp of acid-base balance is a must for this exam. Remember the thought process from start to finish, and remember the differential mnemonics and how to calculate the anion gap, delta-delta, etc. It will prove worthwhile for test day.

true Venous thromboembolus (VTE) should be considered in any patient with pleuritic chest pain, shortness of breath, or leg swelling and pain, along with risk factors. Virchow's triad is the classic set of risk factors to consider when working up VTE. These include stasis, endothelial injury, and any cause of a hypercoagulable state.Acute pulmonary embolism causes ventilation without perfusion, which is the definition of dead space. The physiologic effects of pulmonary embolism and subsequent increased dead space result in a limitation of effective oxygenation and ventilation. Hypoxia occurs as well as hypercapnia, and as a consequence, minute ventilation is increased because of the sensitivity of the chemoreceptors in the brain to carbon dioxide. Increased minute ventilation will cause a respiratory alkalosis by "blowing off" carbon dioxide to combat the deficiency in carbon dioxide exchange. Note that this will not occur in patients who have a suppressed respiratory drive or with baseline hypoventilation. These patients develop respiratory acidosis. Sympathetic innervation to the respiratory system is provided from T2-T7, so expect corresponding somatic dysfunction.Alkalosis is defined as an arterial pH of >7.4, and determination of a respiratory alkalosis versus a metabolic alkalosis depends on the PCO2, which will be <40 mmHg in a respiratory cause and >40 mmHg in a metabolic cause. Other causes of respiratory alkalosis include hyperventilation (anxiety states), early aspirin ingestion, and sepsis.

When evaluating a mole, look for changes in size, shape, and color, as well as border irregularity. These are all strong risk factors for malignancy and should be noted; however, the most important of these is evolution of the lesion.COMBANK Insight : Dermatology is often a neglected subject in preparation for COMLEX. Familiarizing yourself with common dermatologic conditions such as melanoma, squamous cell carcinoma, basal cell carcinoma, atopic dermatitis, acne, and psoriasis will prepare you for commonly tested conditions on the exam.

true When assessing a mole, it is essential to determine size, shape, color uniformity, and border regularity/irregularity. The size of a lesion is not nearly as important as whether or not the lesion is changing in size or shape. Melanoma is the deadliest form of skin cancer and is relatively common in young adults. All of the answers are risk factors in the development of melanoma; however, the presence of any changing lesions (evolution) is the strongest predictor of malignancy among these answer choices. The most important risk factor overall is a history of multiple atypical nevi. Remember the ABCDEs of melanoma: A, asymmetry; B, borders (irregular borders); C, color (change in color: dark brown, red, blue, and white are most concerning); D, diameter (>6 mm diameter), and E, evolution (MOST IMPORTANT of the ABCDEs as a predictor of melanoma).

Bottom Line: It is important to recognize that there are a variety of different tests that can be used to diagnose spondylosis and spondylolisthesis. Initially, you will start with a plain radiograph. Often in true clinical practice, an MRI will follow due to the lack of radiation, but there are a variety of good tests that will diagnosis spondylosis or spondylolisthesis.

true When suspicious of a spondylosis or spondylolisthesis the first test that should be ordered is a plain radiograph. Lateral plain films may show a defect in pars in 80% of films and spondylolisthesis can be used to measure slip angle and grade. Also for spondylolisthesis, flexion and extension films can assess stability. Beyond x-ray there are a variety of tests that can be used to evaluate spondylosis or spondylolisthesis. Choosing the test will depend on the patient. Further imaging is as below: CT: Best study to diagnose and delineate anatomy of a pars defect. A pars lesion will show up as a sclerotic lesion bone scan: the most sensitive study for spondylosis, however, the lesion may be "cold" and not show up MRI: Indicated if there is a neurological symptom. Useful to diagnose associated stenosis central and foraminal. Often used clinically as there is no associated radiation. SPECT: Best diagnostic adjunct when plain radiographs are negative

Venous air embolism is one of the most dangerous complications of central line placement. If suspected, it is appropriate to first attach a syringe to the hub of the catheter immediately to prevent further air entry and attempts should be made to aspirate air through the catheter. Placing the patient on the left side will theoretically prevent the air from entering the left heart, reducing the risk of embolization into the left heart and arterial circulation. Intubation should be performed if there are changes in hemodynamic status and the patient's respiratory status is compromised.

true When venous air embolism is suspected, immediately aspirate the catheter, administer 100% oxygen, and place the patient in the lateral position with left side down.

Bottom Line: Many physiologic changes occur in pregnancy. Some have significant clinical implications. Thyroid-binding globulin is increased by increased estrogen levels, and this needs to be corrected during pregnancy to prevent fetal loss as well as catastrophic neonatal hypothyroidism.

true When you look at the thyroid level given, make sure you are able to differentiate between total T4 in serum and free T4 as well.

Graves' disease, also known as toxic diffuse goiter, is the most common cause of hyperthyroidism and accounts for more than 60% of cases. It is classified as an autoimmune disease and caused by autoantibodies which bind to and activate the thyroid-stimulating hormone (TSH) receptor, causing glandular hypertrophy and the development of thyrotoxicosis. In addition to an elevated T4 and T3 secondary to glandular activation, the autoantibodies can result in an infiltrative ophthalmopathy due to immune activation and edema that gives patients the characteristic "eye-bulging" presentation known as exophthalmos. If there is infiltration of the skin (less common than eye findings), it may cause the notable development of pretibial myxedema which can have a peau d'orange (orange peel) appearance from prominent hair follicles but can also present as firm, nonpitting plaques or nodules. The other systemic symptoms of Graves' Disease are similar in all causes of thyrotoxicosis and felt to be secondary to the activity of excess T3. These symptoms are weight loss with normal or increased appetite due to accelerated metabolism; osteoporosis due to increased bone turnover; palpitations due to effects on cardiac muscle and decreased SA node refractory period; tremors, hyperactivity, sweating and heat intolerance all due to a relative hyperadrenergic state which may be secondary to increased sensitivity of alpha and beta receptors to circulating epinephrine and norepinephrine; severe fatigue (common with hyper and hypothyroidism) which is felt secondary to hypermetabolism and a general inefficiency of energy consumption in the presence of high T3 (studies show a large portion of the energy utilized is converted to heat rather than usable ATP); muscle weakness due to myopathy; decreased cholesterol and triglyceride levels due to effects on the liver; and psychiatric symptoms such as anxiety, depression or mania.Thyroid peroxidase antibodies can be found in numerous conditions that cause autoimmune thyroid disease, including both Graves' Disease and autoimmune thyroiditis.

true be aware Perioral edema would be expected in allergic reactions and cases of angioedema, not in hyperthyroid states. The recurrent laryngeal nerves arise from the vagus nerve and ascend within the neck. They generally course behind the thyroid gland and are easily injured during surgical thyroidectomy. The recurrent laryngeal nerves innervate the vocal cords and are responsible for muscular control of phonation. If both sides are injured, complete chord paralysis can cause airway obstruction. Of note, infiltration of the neck by malignancy can cause compression of these nerves, which is why sometimes laryngeal cancers can present with unilateral vocal chord paralysis. Injury to the RLN is a known complication of thyroidectomy and universally dreaded by head and neck surgeons. It results in loss of vocal chord function, but in a certain number of cases, the function is restored by reanastamosis of nerve fibers or the injury is transient due to inflammation and not transection.

Wilson's disease is an autosomal recessive disease and 1st degree relatives of a patient with Wilson's Disease should undergo genetic screening once treatment has been initiated.

true he clinical manifestations of Wilson disease include the presence of Kayser-Fleischer rings and neurologic manifestations such as parkinsonism, ataxia, and dysphagia. Liver function tests and ceruloplasmin should be checked and will be abnormal in the setting of Wilson disease, with elevated liver enzymes and a depressed ceruloplasmin level (< 20 mg/dL or 200 mg/L). The amount of copper excreted in urine during a 24-hour urinary copper excretion of >100 mcg supports the diagnosis of Wilsons disease. A liver biopsy can be done to measure the hepatic copper concentration. A diagnosis of Wilson disease is established if the hepatic copper concentration is ≥250 mcg/g dry weight. Molecular testing for ATP7B mutation is can also be helpful in the diagnosis of Wilson's disease, especially in siblings of affected patients. Bottom Line: Diagnosing Wilson disease requires a complex, multifactorial approach. The initial lab testing for the diagnosis of Wilson's disease include the following: 24 hour urine copper excretion (>100 mcg) and ceruloplasmin levels (< 20 mg/dL or 200 mg/L) Wilson disease, copper removal is achieved by the administration of potent chelators. The primary chelator that has been used is D-penicillamine. Lifetime therapy aimed primarily at treating copper overload is required in patients with Wilson disease. Treatment should be considered in two phases: removing or detoxifying the tissue copper that has accumulated, and preventing reaccumulation. Copper removal is achieved by the administration of potent chelators. The primary chelator that has been used is D-penicillamine. Trientine has traditionally been used as a second-line agent for those intolerant of D-penicillamine, but it is also a reasonable option for primary therapy, because of its lower incidence of side effects. Prevention of reaccumulation can also be achieved with zinc salts. To further prevent accumulation or reaccumulation of copper, patients with Wilson disease should also be maintained on a low-copper diet.

Bottom Line: By the age of 2 months, children should be alert to sounds and be able to lift their head from their chest when in a prone position, track past the midline, coo, recognize their parents, and exhibit a social smile.COMBANK Insight : Developmental milestones require memorization and are commonly tested. Most of the questions dealing with developmental milestones will give you multiple clues in the case scenario that correspond to a certain age group. Rarely will you be given only one clue. The exceptions to this are questions that provide you with the age of the child and expect you to pick the corresponding milestone. These can be more difficult, but they usually focus on more of the "common" milestones for each age group. Memorizing the list will pick you up a few easy points on exam day. Once again, be ready to answer these questions, as well as questions dealing with childhood immunization schedules.

true note By 4 months, a child should be able to roll front to back, grasp a rattle, orient to voice, and laugh.

Urethritis, which is classically defined as gonococcal (GU) or nongonococcal (NGU), refers to an infected, inflamed urethra. Urethritis can be seen in sexually active persons of any age, although incidence is highest in patients aged 20 to 24 years. As many as 75% of patients with urethritis are asymptomatic upon initial presentation and present following partner screening. The patient in the above case complains of dysuria, which is a common finding among patients with urethritis, but has no suprapubic tenderness as would be expected in this diagnosis.

true ottom Line: It is still reasonable to instruct patients with urethritis to void after intercourse to help prevent recurrences.COMBANK Insight : Interventions with low levels of evidence but no harm and minimal patient effort are often still recommended in clinical practice.

Iron deficiency anemia results from decreased total iron body content. Symptoms of iron deficiency anemia include increased pallor of the mucous membranes, fatigue, glossitis, koilonychia, esophagal webbing, and gastric atrophy. Insufficient iron supplementation when a child drinks primarily cow's milk can be a common cause of iron deficiency anemia in children. Therefore, one should ask the parents if they are supplementing their child's diet with iron.

true treatment is iron supplementation

Bottom Line: The patient is hemodynamically unstable. The patient will need urgent OB/GYN consult for surgical intervention to prevent exsanguination and death.COMBANK Insight : Vague responses such as "consult surgery" or "consult OB/GYN" will be marked as incorrect on your COMLEX exam. You must be specific and state why you need the consult (eg, "Consult OB/GYN for laparotomy").

true 1. Consult OB/GYN for laparotomy 2. Blood transfusion 3. Start vasopressors The patient will need an OB/GYN consult for emergent surgery. On the actual exam, it should be phrased that way. Picking OB/GYN consultation will not be enough. You must specify what you want the consultation for. The decision regarding whether to perform a laparoscopic or open surgery should be left to the obstetric team. In any patient presenting with ectopic pregnancy or with concern for ectopic pregnancy, vitals consistent with shock would be concerning for rupture and hemorrhage into the peritoneal cavity. These patients will require fluid resuscitation, blood products, and immediate surgery to repair the injured vessels and prevent further bleeding. The most common surgical procedure performed is a salpingectomy. Most women who die of a ruptured ectopic pregnancy have rupture before or immediately after arriving to the emergency department.Not all ectopic pregnancies rupture if left untreated. In some percentage of patients, the ectopic pregnancy will abort and be expelled back into the abdominal cavity. This can lead to catastrophic hemorrhage or no bleeding at all, and the embryo may then implant into the ovary or the peritoneal cavity. In some other small percentage of patients, the ectopic pregnancy will resolve and be expelled through the uterus without reimplantation. This was studied in a small series of patients who were managed without surgical intervention; however, this is far from the norm.

Atropine, a muscarinic antagonist, is used as a first-line pharmacotherapy for bradycardia according to the Advanced Cardiac Life Support (ACLS) algorithm. Systemically, such medications can cause dose-related toxicity, which includes confusion, constipation, urinary retention, fever, flushing, tachycardia, blurred vision, and mydriasis. The action of acetylcholine is blocked in postsynaptic receptors, resulting in paralysis of the iris sphincter and ciliary muscle, allowing unopposed action of the iris dilator and lack of accommodation, respectively. This results in a fixed and dilated pupil, meaning the pupil does not react to light and remains dilated.

true Atropine causes mydriasis, dilated pupils, and no response to light stimulation or accommodation due to acetylcholine blockage of the ciliary muscles.

Bottom Line: Diffuse ST elevations and PR depressions in a younger patient without significant risk factors for CAD is usually pericarditis. Treat with high dose of NSAIDs and colchicine.

true 1. echocardiogram 2. trend cardiac enzymes 3. NSAIDs 4. colchicine This EKG is virtually diagnostic of pericarditis. The patient is presenting with sharp substernal chest pressure that radiates to her neck but is young and does not have significant risk factors for coronary disease or myocardial infarction so we must consider other causes of chest pain. Certainly pericarditis, dissection, and pulmonary embolism come to mind but this EKG should suggest pericarditis. Please note that pericardial pain is typically referred to the trapezius/neck area as in this patient and her history of travel could be suggestive of exposure and infection risk that may lead to pericarditis. Although we are told she does not have a friction rub, this does not rule out the diagnosis. Many patients will not have a friction rub. Additionally, it may be transient.Typical EKG features of pericarditis include: Widespread concave ST elevation and PR depression throughout most of the limb leads (I, II, III, aVL, aVF) and precordial leads (V2-6). Reciprocal ST depression and PR elevation in lead aVR (± V1) Sinus tachycardia is common due to pain or a pericardial effusion The management of pericarditis includes high dose NSAIDs for several weeks and several months of colchicine. An echocardiogram can be helpful to evaluate for a significant pericardial effusion (given her tachycardia and distant heart sounds). In patients who are at a higher risk for a myocardial infarction and have more subtle EKG changes, an echocardiogram is even more important to look for regional wall motion changes that could be explained by ischemia.Bottom Line: Diffuse ST elevations and PR depressions in a younger patient without significant risk factors for CAD is usually pericarditis. Treat with high dose of NSAIDs and colchicine.

Bottom Line: Bilateral ureterolithiasis can cause obstructive nephropathy.

true A complication of bilateral nephrolithiasis is postrenal acute renal failure secondary to urinary outflow obstruction. Nephrolithiasis, or renal calculi, are usually composed of calcium oxalate but may also be composed of calcium phosphate, struvite, uric acid, or cysteine. Risk factors include a positive family history, low fluid intake, gout, medications such as allopurinol, chemotherapy and loop diuretics, enzyme deficiencies, type I renal tubular acidosis, and hyperparathyroidism. It usually presents in older males but may also occur in other age groups. It presents with acute onset of severe, colicky flank pain that may radiate to the testes or vulva and can be associated with nausea and vomiting. Patients are often unable to get comfortable and shift position frequently. Urinalysis may show gross or microscopic hematuria and altered urine pH. A KUB (kidneys, ureter, bladder) radiograph identifies radiopaque stones but will miss 10% of stones that are radiolucent. A noncontrast abdominal CT scan is the gold standard for the diagnosis of kidney stones. Hydration and analgesia are the initial treatments. Postrenal failure can be caused by any cause of urinary outflow obstruction such as renal stones or prostatic disease. Labs indicating postrenal failure include a urine osmolality <350 mOsm/kg, urine sodium >40 mEq/L, and a blood urea nitrogen to creatine ratio (BUN/Cr) of >15. Viscerosomatic reflexes are a type of somatic dysfunction caused by changes in the autonomic nervous system. They can be acute or chronic and are considered to be a somatic representation of visceral disease. When either branch of the autonomic nervous system (sympathetic or parasympathetic) overstimulates a particular organ, a reflex reaction occurs. The soma at the same level of the organ's autonomic innervation takes on characteristics of somatic dysfunction (TART [tenderness, asymmetry, restricted motion, and tissue texture changes]). T12-L1 is where the sympathetic viscerosomatic reflex for the distal ureter is located. T10-T11 is where the sympathetic viscerosomatic reflex for the proximal ureter is located.The osteopathic findings described also illustrate acute findings in somatic dysfunction, versus chronic changes. Acute and chronic somatic dysfunction findings differ in tissue texture changes, restriction, and tenderness. In patients with chronic somatic dysfunction, the tissue texture changes are cool, dry, flaccid, ropy, and fibrotic. The restriction is present, but there is decreased or no pain. Tenderness in chronic somatic dysfunction is described as dull, achy, and burning. Acute tissue texture changes are edematous and erythematous, with increased tonicity of muscles. The restriction is present and is painful with movement. Acute tenderness is described as severe and sharp.

IV fluids are indicated in the presence of an inferior/right-sided infarct to maintain preload.

true A right ventricular infarct is unique in the sense that it is treated slightly differently than other MIs. Aspirin, heparin, and oxygen therapy are still indicated, as in any other MI. However, nitrates, which are typically used in acute coronary syndrome, will exacerbate the patient's condition by decreasing preload. In the case of a right ventricular infarct, the patient is extremely preload dependent because the right ventricle is not functioning to pump blood to the lungs and the left side of the heart. In fact, aggressive IV fluids are usually indicated in order to maintain preload. In a sense, the right ventricle ceases to be a pump and becomes a conduit; pressure is necessary to provide the flow, which is maintained by volume (e.g., fluids). Nitrates, by reducing preload, would exacerbate this situation.

ottom Line: Always suspect a secondary cause of hypertension in a young patient without risk factors for hypertension. This patient gives a history most consistent with pheochromocytoma.

true A work-up for secondary causes of hypertension should be considered in patients less than 30 years-old who are non-African American, have a negative family history, and have no other risk factors for hypertension. Other clues that suggest a secondary cause of hypertension include severe or resistant hypertension, which is an acute rise in blood pressure in a previously well controlled patient or in a patient with hypertension diagnosed prior to the onset of puberty. Work-up for secondary causes includes serum cortisol to evaluate for Cushing's syndrome, serum metanephrines to evaluate for pheochromocytoma, and serum renin levels to evaluate for primary hyperaldosteronism. A renal artery ultrasound can also be ordered to evaluate for renal artery stenosis.This patient gives a history consistent with possible pheochromocytoma. Elevated metanephrine levels indicate pheochromocytoma, which presents with hypertension, in addition to headaches, palpitations, and episodic sweating. Diagnosis is with increased urine or plasma metanephrines and normetanephrines, and management is accomplished with surgical resection. Patients need preoperative alpha blockade. Biochemical testing should confirm the diagnosis, and then imaging can be used to localize an adrenal adenoma or venous sampling will be needed to evaluate for the secretion of catacholamines.

Bottom Line: Consider bladder diverticula in male patients who have a known diagnosis of BPH and present with symptoms of frequent, recurrent, urinary tract infection.

true Acquired diverticula of the bladder are usually related to bladder obstruction and most commonly occur as a result of benign prostatic hyperplasia (BPH). Bladder diverticula are also common following urethral surgery. Bladder diverticula and vesicourachal diverticula are mostly asymptomatic, but in symptomatic cases, patients most often present with symptoms of urinary tract infection secondary to stasis of urine and mucosal inflammation. The x-ray of the bladder clearly demonstrates the presence of multiple diverticulum, making the diagnosis easy. Bladder diverticula are herniations of the bladder mucosa through the bladder wall musculature (detrusor muscle) and are similar to diverticula found in the colon and small bowel. Diverticular size can vary greatly, with some attaining a size equal to or greater than the volume of the bladder. Diverticula can be wide or narrow-mouthed, as dictated by the size of the musculature (detrusor) defect. The size of diverticular openings has functional implications because narrow-mouthed diverticula often empty poorly. Stasis of urine within diverticula can also lead to stone formation or epithelial dysplasia as well as frequent urinary tract infections and mucosal irritation leading to pyuria and hematuria which can sometimes be pronounced on double-voiding. The first void empties the native bladder and subsequent voids empty the diverticula where static urine is present.

This patient is having a febrile non-hemolytic transfusion reaction (FNHTR), which is one of the more frequent reactions associated with transfer of cellular blood products. The reaction occurs due to recipient antibodies directed against donor leukocytes. The leukocytes are lysed and cytokines are released resulting in fever and chills. The build-up of cytokines during storage of blood products is another possible cause. The incidence and severity of the reaction cannot be reduced by premedicating with acetaminophen. The incidence of FNHTR is declining due to the practice of leukoreduction prior to the storage of blood products.

true Acute hemolytic reaction can present with fever, chills, hypotension, hemoglobinemia, hemoglobinuria, chest and/or flank pain. Treatment includes maintaining intravascular volume and renal function with IV fluids and diuretics.Delayed hemolytic reaction can present with mild anemia and/or hyperbilirubinemia with a slight fever that can occur 3-10 days following transfusion. Treatment is similar to acute hemolytic reactions.Febrile non-hemolytic reaction is characterized by chills and a rise in temperature > 1C. Although common, it is usually a diagnosis of exclusion because the more serious acute hemolytic reaction and bacterial contamination can present similarly. Symptoms can be prevented by leukoreduction. Treatment includes acetaminophen.Allergic reaction is characterized by urticaria. It can be treated by temporarily by stopping the transfusion and treating with antihistamines.Anaphylactic reaction is a severe reaction manifested by difficulty breathing. It can result in loss of consciousness, respiratory arrest, and shock. Treatment includes stopping transfusion immediately and administering epinephrine. Previous anaphylactic reactions necessitate pretreatment with glucocorticoids and washed RBCs or volume-reduced platelets.In bacterial contamination, patients suddenly develop fever and chills minutes to hours after initiation of transfusion and can progress to septic shock and DIC. Treatment includes maintaining the patient's blood pressure and broad-spectrum antibiotics.

Acute lymphoblastic leukemia presents in a 2- to 5-year-old child with fever, pallor, petechiae, and lymphadenopathy.

true Acute lymphoblastic leukemia (ALL) has a peak incidence between ages 2 and 5. Symptoms reflect bone marrow infiltration (blasts replacing bone marrow) and include anemia (pallor, fatigue), thrombocytopenia (petechiae), and neutropenia or leukocytosis. Upon initial evaluation, obtain a complete blood cell (CBC) count. A hematologist or hematopathologist must evaluate the peripheral smear for the presence and morphology of lymphoblasts. An elevated leukocyte count of more than 10 × 103/mcL occurs in one-half of patients with ALL. Neutropenia, anemia, and thrombocytopenia are often observed secondary to inhibition of normal hematopoiesis by leukemic infiltration. It is important to recognize that 20% of patients with ALL initially present with pancytopenia and no evidence of peripheral blasts.

Klinefelter syndrome has distinct physical exam findings due to increased level of estradiol and estradiol-to-testosterone ratio.

true Additional physical exam findings in Klinefelter syndrome include taller height, disproportionately longer limbs, firm and small testicles, high-pitched voice, female fat distribution, mitral valve prolapsed, and venous disorders.

This is an erythematous rash with central clearing, which is pathognomonic for Lyme disease. Upon traveling to tick-endemic areas, one is advised to take caution when outdoors by wearing long pants that fully cover the lower extremities. There is no way to prevent tick bites 100% of the time, but by wearing long pants and frequently inspecting extremities, a tick may be found before it has a chance to transmit infection.

true Advise patients to take precautions (wear protective clothing, check for and remove ticks, and use insect repellent) when traveling to tick-infested areas.

When the seated flexion test, anterior sacral base, and posterior ILA findings are all on the same side, this indicates a diagnosis of unilateral sacral flexion.

true Anterior sacral base and posterior ILA findings are both on one side, which point us to a unilateral sacral flexion. A positive seated flexion on the right indicates the dysfunction is localized to that side. Since the right sacral base (the superior portion of the sacrum) is anterior and the right ILA (the inferior portion of the sacrum) is posterior, the right side of the sacrum is nutated, or flexed, in relation to the left side of the sacrum. The correct treatment describes a portion of muscle energy modified by utilizing respiratory cooperation instead of the patient's active force. Muscle energy is a direct technique that involves engaging the restrictive barrier and pushing the sacrum back toward neutral. The right ILA is posterior and the right sacral base is anterior, so pushing anteriorly on the ILA would engage the restrictive barrier and help to restore normal sacral motion. Treating a unilateral sacral flexion with muscle energy involves moving the ILA on the involved side anteriorly and the sacral base posteriorly.

Bottom Line: There are numerous risk factors for ectopic pregnancy. The most common are a previous ectopic pregnancy, surgery, and history of pelvic inflammatory disease or pelvic infection.

true Anything that causes disruption of the normal tubal anatomy is a risk for ectopic pregnancy. This could be something like previous tubal surgery, infection, or tumor as well as congenital abnormalities. Of all the risk factors, previous ectopic pregnancy and tubal surgery carry the highest risk of recurrence. The whole list of risk factors is extremely long and includes infertility (because women who struggle with infertility issues may have abnormal tubal anatomy and, if they do become pregnant, there is increased risk for ectopic pregnancy), in vitro fertilization, tubal surgery, previous attempts at sterilization, presence of an intrauterine device with the development of pregnancy, smoking, in utero diethylstilbestrol, douching, and increasing age.Previous ectopic pregnancy is a risk factor that increases the chances of an ectopic pregnancy by between 3- and 8-fold. In medicine, generally, the history of a condition is a risk factor in itself for recurrence. In the case of ectopic pregnancy, this is due to the initial reason for the first ectopic pregnancy (which cannot usually be treated) and possibly due to the method of treatment. In the past, salpingostomy may have been used, which can increase the risk for further ectopic pregnancies.History of tubal surgery is a risk factor that increases the chances of an ectopic pregnancy. As noted earlier, any alteration in normal anatomy can impact tubal ciliary function and prevent the passage of the developing embryo into the uterus.Douching is a known risk factor that increases the chances of an ectopic pregnancy. It should generally be avoided because it alters the normal vaginal pH, which can lead to recurrent vaginal infection; however, it is still widely practiced, and some women feel it keeps them cleaner. There is no agreed-upon mechanism for the development of ectopic pregnancy after douching, but it may be due to ascending infection and alterations in fallopian tube function.In utero exposure to diethylstilbestrol is a risk factor that increases the chances of an ectopic pregnancy. This is one of the causes of abnormal tubal morphology and physiology with possible impairment of fimbrial function.Pelvic inflammatory disease is a risk factor for the development of ectopic pregnancy by altering tubal function. Infection can cause the development of adhesions, which can partially or completely block a fallopian tube.

Bottom Line: Angiotensin-converting enzyme inhibitor or angiotensin receptor blocker therapy should be initiated in a hypertensive patient with advanced chronic kidney disease and/or significant albuminuria.

true As per JNC-8 guidelines, the most appropriate next steps for this patient would be to add an angiotensin-converting enzyme inhibitor (ACEI)/angiotensin receptor blocker (ARB) given his elevated blood pressure, chronic kidney disease (CKD), and noted proteinuria. ACEI/ARBs are first-line medications for blood pressure; however, they are slightly less efficacious in African Americans and, as such, are not recommended before the use of a diuretic or calcium channel blocker (CCB) unless there is another comorbidity present such as diabetes or CKD, as in this patient. This patient has already been started on 1 antihypertensive, and thus, even without CKD or diabetes, he could be started on an ACEI/ARB as a second-line agent (or a CCB), although caution should be used in African Americans due to increased risk of angioedema. That is why some practitioners are going straight to ARBs in African Americans.

Bacterial vaginosis (BV) represents a change in the normal bacterial flora of the vagina. The definition of BV includes a rise in vaginal pH over 4.5, bacteria that produce certain chemicals that can be detected by smell, and a shift in normal flora. Risk factors for BV include, but are not limited to, history of sexually transmitted infections, smoking, sexual activity, and possibly genetic and dietary factors.About one-half of women with BV are asymptomatic. Symptomatic women may have vaginal discharge with the characteristic "fishy" odor. BV, unless in the presence of other bacterial pathogens, does not typically cause pain or burning. The diagnosis of BV is made using the Amsel criteria, of which 3 must be present: Gray/white discharge that coats vaginal walls Vaginal pH >4.5 Positive "whiff" test (a fishy odor when potassium hydroxide is added to a sample of vaginal discharge) Presence of clue cells on wet mount; clue cells are epithelium obtained from a vaginal sample that are surrounded by coccobacili; this is considered the single most reliable predictor of BV. A picture of a clue cell is shown below.

true Bacterial vaginosis (BV) represents a change in the normal bacterial flora of the vagina. The definition of BV includes a rise in vaginal pH over 4.5, bacteria that produce certain chemicals that can be detected by smell, and a shift in normal flora. Risk factors for BV include, but are not limited to, history of sexually transmitted infections, smoking, sexual activity, and possibly genetic and dietary factors.

Patient privacy preferences and requests, although at times may result in a lost opportunity for patient interaction, must be honored, when requests are within reason. Despite patients asking for trainees to not be present during an interaction when rounding, there are still educational opportunities to be had after the attending physician is finished with the interaction.

true Because physicians and other members of the healthcare team have the objective of taking care of the patient, reasonable patient preferences and requests must be honored, especially regarding patient privacy. If a patient requests that there are not to be other trainees present during an interaction, they are certainly within their rights to do so, and all involved should honor this request if possible. Certain hospitals are resident-run and attending physicians are not available at all hours so obviously, in this case, requesting not to see residents would be impossible (additionally, they are licensed physicians and generally not considered to be on the same level as students).

This patient has acutely decompensated aortic regurgitation and decompensated heart failure caused by endocarditis. Acute aortic regurgitation necessitates urgent or emergent surgical intervention. This is because the heart has not had time to develop compensatory eccentric and concentric hypertrophy as seen in chronic aortic regurgitation. In aortic regurgitation, the increase in diastolic return from the aorta into the left ventricle results in left ventricular dilation, pulmonary edema, ventricular arrhythmias, and cardiovascular collapse.Acute aortic regurgitation alters the quality of most of the heart sounds as follows: The early closure of the mitral valve causes a soft or absent S1, heard in mid-diastole. The aortic component of S2 is soft and P2 is increased, reflecting pulmonary hypertension. An S3 is present, and S4 is absent. The murmur with acute aortic regurgitation is a low-pitched early diastolic murmur beginning after S2. The treatment for acute severe aortic regurgitation that causes sudden decompensated heart failure is emergency aortic valve replacement or repair. If there is delay in surgery, temporary stabilization with intravenous vasodilators, such as nitroprusside, and inotropic agents, such as dobutamine, is required. These agents will improve forward flow and lower the left ventricular diastolic pressure and pulmonary venous pressure. Although nitroprusside is a vasodilator, it can reduce afterload, which increases forward flow and can improve blood pressure by offloading the left ventricle. Although confusing, this is a good application of physiology. Alternative medications, such as norepinephrine, will increase afterload, worsen aortic regurgitation, and worsen the patient's cardiogenic shock, resulting in death. This therapy is endorsed by both the American College of Cardiology and American Heart Association as short-term therapy before proceeding with valve replacement and can be used safely even in hypotensive patients with close monitoring in the cardiac intensive care unit.

true Bottom Line: Aortic regurgitation is described as acute or chronic, with the former necessitating emergent surgical repair with temporizing medical care with nitroprusside and/or inotropic drugs such as dobutamine.

This patient most likely has hyperkalemia, as evidenced by the peaked T waves, which are greater than half the R amplitude. Intravenous (IV) calcium gluconate should be given immediately to stabilize the cardiac membrane and is the initial treatment of choice. Once the ECG changes have resolved with IV calcium, further measures should be taken to urgently lower the serum potassium concentration. Increased potassium levels cause a decrease in cell membrane potentials in cardiac tissue and can be visualized on the ECG as peaked T waves and a widening QRS interval. Treatment of hyperkalemia aims to decrease serum potassium concentration and stabilize cardiac myocytes. There is no absolute number that requires treatment, but serious complications usually occur with potassium levels >6.5 mEq/L. Treatment of acute hyperkalemia with ECG changes include:- IV calcium gluconate or IV calcium chloride. IV calcium can enhance the effect of digoxin, so do not give to patients on this therapy.- Insulin/glucose infusion usually needs 15 minutes for effect and uses the sodium/potassium ATPase to force potassium out of the serum and back into cells.- Sodium bicarbonate injection or infusion if the patient is acidotic; usually needs 15 minutes for full effect and has minimal effects in patients without acidosis.- Albuterol nebulizers need up to 90 minutes for full effect. Avoid in patients with heart disease.- Loop diuretics if patients can urinate.- Dialysis.- Sodium polystyrene sulfonate can be given, but it is not used to treat severe hyperkalemia because it can take hours to work.Treat hyperkalemia >6.5 mEq/L without symptoms or ECG changes with insulin plus glucose, a beta-agonist, sodium bicarbonate if acidosis is present, and sodium polystyrene sulfonate. Potassium levels <6.5 mEq/L can be treated with diuretics and dietary restrictions only if there are no ECG changes present.

true Bottom Line: Calcium reverses the effects of potassium on the membrane potential and is the most rapid way to correct arrhythmia associated with hyperkalemia.

Ophthalmia neonatorum is a term used to describe a conjunctivitis occurring within the first month after birth. The causes vary and can be differentiated by time of presentation. In the most developed countries, prophylactic erythromycin or tetracycline ophthalmic ointment is used to prevent possible infection acquired from the birth canal. However, 2% silver nitrate was previously used and may still be used in other parts of the world. Chemical conjunctivitis presents within the first 24 hours of birth and is due to exposure to any one of many chemical compounds including prophylactic ointments. It is a self-limited eye redness and irritation that requires no treatment. Viscerosomatic reflexes are a type of somatic dysfunction caused by changes in the autonomic nervous system. They can be acute or chronic and are considered to be a somatic representation of visceral disease. When either branch of the autonomic nervous system (sympathetic or parasympathetic) overstimulates a particular organ, a reflex reaction occurs. The soma at the same level of the organ's autonomic innervation takes on characteristics of somatic dysfunction (TART). T1-T4 is where the sympathetic viscerosomatic reflex for the head and neck is located. The osteopathic findings described also illustrate acute findings in somatic dysfunction, versus chronic changes. Acute and chronic somatic dysfunction findings differ in tissue texture changes, restriction, and tenderness. In patients with chronic somatic dysfunction, the tissue texture changes are cool, dry, flaccid, ropy, and fibrotic. The restriction is present, but there is decreased or no pain. Tenderness in chronic somatic dysfunction is described as dull, achy, and burning. Acute tissue texture changes are edematous and erythematous, with increased tonicity of muscles. The restriction is present and is painful with movement. Acute tenderness is described as severe and sharp.

true Bottom Line: Chemical conjunctivitis presents during the first day of life, and management consists of reassurance and observation. COMBANK Insight : Although not mentioned in the stem, this child was likely exposed to silver nitrate as the cause of the conjunctivitis. On the actual COMLEX exam, you will be required to know the days at which common causes of neonatal conjunctivitis appear with minimal background information. The major forms of conjunctivitis can be differentiated by their time of onset after birth with almost no other supporting information.

Chronic sun exposure is by far the most important preventable risk factor in the development of melanoma, as shown here. Melanoma is a malignancy of melanocytes, which are pigment-producing cells located predominantly in the skin but also found in the eyes, ears, gastrointestinal tract, and oral and genital mucous membranes. Melanoma accounts for a mere 4% of all skin cancers but causes the greatest number of skin cancer-related deaths worldwide. The projected lifetime risk of developing melanoma in the year 2000 was 1 in 75. Factors that increase the risk of developing melanoma include fair skin (Fitzpatrick skin types I and II), presence of atypical nevi, personal or family history of melanoma, history of blistering sunburns, and congenital nevi (the risk increases proportionally with the increasing size of these lesions).The most common early signs of melanoma include the ABCDEs of melanoma, which are as follows: asymmetry of the lesion border irregularity color variation or change diameter greater than 6 mm evolution or change within the lesion Approximately 70% of lesions develop de novo, whereas 30% develop within a preexisting nevus. There are 4 major types of melanoma, the most common being superficial spreading melanoma, which accounts for 70% to 80% of all melanomas. Nodular melanomas have a vertical growth phase and are rapidly spreading. Lentigo maligna melanoma develops within lentigos and is the slowest growing. Acral lentiginous melanoma develops more commonly on males, particularly on those with darker skin types. Workup of a suspicious lesion involves complete excision or excisional biopsy.

true Bottom Line: Chronic sun exposure is the most important preventable risk factor in the development of melanoma.COMBANK Insight : Be familiar with the risk factors for melanoma, as well as the use of excision in the biopsy of these lesions. Bottom Line: Tumor thickness is the most important prognostic factor on biopsy, and a depth of invasion >0.8 mm is an indication for sentinel lymph node biopsy.

Tracheomalacia is a relatively common anomaly of the upper respiratory tract characterized by a dynamic collapse of the trachea during expiration, resulting in airway obstruction. Intrathoracic lesions typically present with recurrent harsh, barking, or croup-like cough, whereas extrathoracic lesions cause wheezing with expiratory stridor common if laryngomalacia is present. This condition should be suspected in children with chronic wheezing.

true Bottom Line: Consider tracheomalacia in a child with chronic wheezing.

The clinical presentation is highly suggestive for acute alcohol withdrawal syndrome. Delirium tremens typically presents within 48 to 96 hours after cessation of alcohol consumption. Symptoms include tachycardia, psychomotor agitation, combativeness, hypertension, and fever. Left untreated, it can be fatal. Treatment is with intravenous benzodiazepines to control psychomotor agitation as well as supportive measures.Answer A: Alcohol intoxication presents with slurred speech, gait disturbances, altered mental status, nausea, and vomiting.

true Bottom Line: Delirium tremens typically presents within 48 to 96 hours after cessation of alcohol consumption. Symptoms include tachycardia, psychomotor agitation, combativeness, hypertension, and fever. Left untreated, it can be fatal. Treatment is with intravenous benzodiazepines to control psychomotor agitation, and supportive measures.

This patient is presenting with a compression strain of the sphenobasilar synchondrosis, which was likely due to stress on the occiput during birth. This compression strain affects the hypoglossal nerve and results in poor sucking in an infant. A condylar decompression would decrease the strain on the hypoglossal nerve and should help the infant's sucking.

true Bottom Line: Dysfunction of the XII cranial nerve leads to dysphagia and can manifest as poor swallowing in a neonate.COMBANK Insight : Cranial questions, while not extensively studied by research, will show up on your exam. Focus your studying on the cranial chapter in Savarese's review book.

This patient's cervix is fully dilated and the fetal heart tracing shows head compression. Therefore, the patient needs to start pushing and the anticipated mode of delivery would be a vaginal delivery. Early decelerations are expected during active labor and when the patient starts to push. This deceleration should not alarm the physician as long as the fetal heart rate returns to baseline after the contraction subsides. There is no need to prepare for an operative vaginal delivery or an emergent Cesarean section at this point.

true Bottom Line: Early decelerations are expected during active labor. The presence of these decelerations does not require the need to deviate from a spontaneous vaginal delivery.

The cervical and thoracic MRIs look similar, with adjacent epidural abscess but without osteomyelitis. Abscess adjacent to the spine causes compressive neuropathy, which causes upper motor neuron signs below the level of the lesion and lower motor neuron signs near the level of the lesion. Given that this patient has lesions throughout the cord, he is expected to have mixed signs depending on which part of the cord is compressed. If the axons carrying inhibitory fibers from the cortex are compressed, upper motor neuron signs will predominate. If there are levels where the alpha motor neurons are compressed, lower motor neuron signs will predominate at those levels. This patient has signs of mostly upper motor neuron disease, with significant epidural abscess and compression. Abscess of more than 5 levels is considered extensive and carries a 15% mortality rate. This patient should be taken for surgery as soon as possible for decompressive laminectomy and drainage before there is permanent neurological injury.

true Bottom Line: Epidural abscess with symptoms of cord compression is a neurosurgical emergency and patients should be taken for decompressive surgery as soon as possible.

Hemophilia A is the most common hemophilia and is inherited in an X-linked recessive fashion. Therefore its clinical effects are seen primarily in males. The underlying pathogenesis is secondary to a decrease in the amount or the activity of factor VIII. Factor VIII is a cofactor for factor IXa. Because factor VIII is only involved in the Intrinsic pathway of the coagulation cascade, only the PTT would be increased. The Intrinsic pathway involves factors XII, XI, IX, VIII, X, V, II, and I. Therefore, Hemophilia B (Factor IX deficiency) would also show an increased PTT in the context of a normal PT & bleeding time.Multiple inherited or acquired bleeding diathesis occur and are frequently encountered clinically or academically. Although not all coagulation studies are performed in practice characteristics are useful for determining cause, treatment, and prognosis. In the table below common clinical manifestations and findings encountered through coagulation studies are summarized. Pathogenesis and treatment can be reviewed by following the references and links provided.

true Bottom Line: Hemophilia A is caused by a deficiency in Factor VIII, which manifests as an increase in PTT with normal PT and Bleeding Time. Be able to differentiate this from other bleeding diathesis using clinical reasoning and coagulation markers.COMBANK Insight : Coagulopathies are encountered frequently in clinical practice and must be understood. The COMLEX tests them accordingly. It is important to know the laboratory profiles for these disorders as you will likely encounter on test day. We do not recommend that you spend too much time reviewing the cascade, but rather understand the clinical presentations for each disorder and how to manage them appropriately. Hemophilia B, aka as Christmas disease is due to factor IX deficiency. Christmas has 9 letters in it.

The Good Samaritan Act was written to protect healthcare professionals from potential law suits that might deter them from providing medical care to persons in emergent situations. The act states that a person who renders emergency care or aid to an ill, injured, or unconscious person at the immediate scene of an accident or emergency is not liable for damages related to injury and/or death of that person. Although Good Samaritan Laws provide protection for good-faith efforts, they do not by any means make the volunteer exempt from lawsuits. A healthcare professional should not leave a patient unless care is transferred to an equally competent individual. Negligence and gross misconduct can never be defended.

true Bottom Line: If you ever see someone in distress and in need of urgent medical care, don't leave the patient until you are able to place him/her in the hands of a competent medical professional.COMBANK Insight : Never leave the scene of an accident until EMS personnel have arrived if you have begun administering care. The Good Samaritan Laws are designed to protect healthcare professionals who provide volunteer medical services during emergent situations from potential lawsuits. As stated in the previous explanation, neglect and gross misconduct are not defensible under any circumstance. To best protect himself from a potential lawsuit, the physician should have remained with the patient at all times until care was transferred to emergency medical services (EMS).

Ordering a PT/PTT would be the most appropriate initial step in the management of this patient. PT and PTT help identify defects of clotting factors and the coagulation cascade. As factor VIII is involved in the intrinsic pathway, PTT prolongation is seen in isolation in coagulation studies with hemophilia. This test can be used in conjunction with a CBC to quantify platelets and bleeding times to identify qualitative platelet dysfunction. Although PT and PTT do not identify the specific clotting factor, testing is a good initial study, as it provides useful information pertaining to diagnosis and is relatively inexpensive, with results readily available. All patients will require factor activity levels thereafter to identify the specific defects.

true Bottom Line: In the setting of abnormal or prolonged bleeding, a PT/PTT should be ordered initially to assess coagulation. If abnormal, this can be followed by testing to determine specific clotting factor deficiencies.

Endoscopic retrograde cholangiopancreatography (ERCP) is both diagnostic and therapeutic. In a patient with Charcot triad or Reynolds pentad, urgent ERCP is the best test. Although some patients respond to IV antibiotics alone, ERCP is still needed to decompress the biliary tree in a septic patient.

true Bottom Line: In the setting of acute ascending cholangitis, management includes treatment of shock with fluid resuscitation, broad-spectrum IV antibiotics, and biliary decompression. Endoscopic retrograde cholangiopancreatography (ERCP) is both diagnostic and therapeutic, making it the best test when there is a very high suspicion for acute cholangitis in a septic patient. Otherwise transabdominal ultrasound is less invasive and can usually confirm the presence of biliary dilatation and stones.

Thoracic inlet release is the first procedure that should be performed to open up her lymphatic passageways. It is done gently and is safe in the setting of recent trauma. It can also be performed while she is laying on her back comfortably. Lymphatic return is always initiated near the lymphatic duct, then extended peripherally.

true Bottom Line: Lymphatic drainage techniques should always begin proximally and move distally.

Mallory-Weiss syndrome involves superficial erosions in the esophageal mucosa at the gastroesophageal junction. It is due to prolonged vomiting and retching. Patients typically have a history of excessive alcohol drinking or eating disorders such as bulimia nervosa. Patients present with a sudden onset of hematemesis after vomiting. Patients may have a case of hypochloremic, hypokalemic, and metabolic alkalosis caused by the vomiting. The test of choice is endoscopy, and management is conservative. Serious cases warrant epinephrine, electrocautery, and vasopressin.

true Bottom Line: Mallory-Weiss tearing is due to lacerations at the gastroeshophageal junction following episodes of vomiting and retching, and patients present with hematemesis.

Ovarian cancer is the most common cause of death resulting from gynecologic tumors in the United States. Most cases occur in the seventh decade of life. Presenting symptoms include abdominal or pelvic pain, bloating, distention of the abdomen, and changes in bowel and bowel habits. Currently, screening is not recommended by the US Preventive Services Task Force (USPSTF) and the American Cancer Society. Evaluation should begin with a thorough history and physical/pelvic examination. Transvaginal ultrasound and CA-125 can help support further evaluation if suspicion is high. Definitive diagnosis is made from tissue obtained during a laparotomy

true Bottom Line: Pelvic examination should be the first step in the evaluation of ovarian cancer. Currently, routine screening is not recommended for ovarian cancer by the American Cancer Society or the US Preventive Services Task Force. A recent study conducted by the National Cancer Institute using a combination of transvaginal ultrasound and CA-125 levels as a way to screen for and prevent deaths from ovarian cancer showed no decrease in deaths from ovarian cancer. In fact, the USPSTF concluded that screening for ovarian cancer can lead to important harms, including major surgical interventions in women who do not have cancer.

This patient is presenting with signs and symptoms of left-sided systolic heart failure. Systolic heart failure is due to weakening of the pumping function of the heart. Chronic hypertension is a common cause; other causes include ischemic heart disease and cardiomyopathy. Blood backs up into the lungs, resulting in dyspnea, rales, and eventually pulmonary edema. Other physical findings include an S3 heart sound. Echocardiography is diagnostic. Loop diuretics and nitrates are given to quickly relieve the pulmonary hypertension. Maintenance medications include beta-blockers, angiotensin-converting enzyme inhibitors, and spironolactone. Automatic implantable cardiac defibrillators are indicated in patients with an ejection fraction of less than 35% and have been shown to decrease mortality rates from dysrhythmia.

true Bottom Line: The first line of treatment for pulmonary hypertension due to congestive heart failure is loop diuretics and nitrates.

The above patient has a clinical scenario most suggestive of umbilical cord prolapse, which is a surgical emergency. These findings indicate the need for an emergent cesarean section. Risk factors for umbilical cord prolapse include low birth weight, premature delivery, multiparity, and anatomic abnormalities of the pelvis/cord. Patients are also at increased risk for cord prolapse with obstetric interventions. Commonly, the patient or the physician feels a pulsation during a cervical check. If the cord is felt while checking a patient, the fetal head should be displaced off the cord and the hand kept in the vagina until the baby is delivered.

umbilical cord prolapse,

This patient is suffering from secondary amenorrhea, which is defined as cessation of menses for 3 or more months in women who previously had regular menstruation for 6 months. It should be worked up in a stepwise fashion, beginning with a pregnancy test (because pregnancy is the most common cause of secondary amenorrhea). If the test is negative, then thyroid-stimulating hormone (TSH), follicle-stimulating hormone (FSH), and prolactin levels should be assessed. If all of these are within normal limits, then less common causes should be investigated.

true Bottom Line: The most common cause of secondary amenorrhea is pregnancy, and thus the first step in evaluation should always be a pregnancy test. If that is negative, the next step would be to check follicle-stimulating hormone, thyroid-stimulating hormone, and prolactin levels. Additional tests can be considered based on physical exam and history, such as testosterone levels in the setting of suspected hyperandrogenism.COMBANK Insight : The workup of amenorrhea is extremely high yield on COMLEX Level 3. Differentiating between primary and secondary amenorrhea is the first step toward getting the answer correct. Remember, ALWAYS order a pregnancy test first unless you are told it is negative in the case scenario.

Medical management should be the initial treatment for most patients, if clinically appropriate. Once the acute bleeding episode has been controlled, transitioning the patient to long-term maintenance therapy is recommended.

true Bottom Line: Women at low risk of endometrial cancer and women with benign endometrial histology who have continued irregular or excessive uterine bleeding despite treatment should undergo imaging to rule out concomitant structural changes.

Bottom Line: Bronchoscopy is considered the gold standard to diagnose tracheomalacia.

true Bronchoscopic visualization of dynamic airway compromise is the diagnostic gold standard for tracheomalacia (TM). TM is considered mild if the operator estimates that the lumen narrows to 50 percent of its initial size during expiration, moderate if it narrows to 25 percent of its initial size, and severe if the anterior and posterior walls touch. Treatment is routine follow-up with surgical options only considered if airway compromise is evident, which is rare.

Bottom Line: In a patient with suspected carbon monoxide poisoning, empiric therapy with high-flow oxygen should be started regardless of pulse oximetry or arterial PO2. While an arterial blood gas needs to be obtained, initial treatment in a patient with history and findings highly suspicious for carbon monoxide poisoning would not be altered by its findings. Multiple sources, including the American Thoracic Society practice guidelines, recommend for initial management to begin with high-flow oxygen regardless of pulse oximetry or arterial PO2. Arterial blood gas may guide subsequent therapy including intubation or utility of hyperbaric oxygen treatment.

true Carbon monoxide poisoning is frequently encountered in the setting of smoke inhalation. Non−fire-related exposures include heating systems, wood-burning stoves, charcoal grills, and motor vehicle exhaust in enclosed spaces. Carbon monoxide readily binds the iron component of heme with 240 times the affinity of oxygen, altering the shape and diminishing the ability of the other 3 oxygen-binding sites to release oxygen to peripheral tissues. Diagnosis is suspected clinically by history of exposure and nonspecific symptoms including chest pain, dyspnea, nausea, dizziness, or malaise, or, more significantly, confusion, coma, or seizures. Diagnosis is confirmed with measurement of carboxyhemoglobin. The staple of treatment is with oxygen therapy because it decreases the half-life of carboxyhemoglobin from 5 hours to 90 minutes. Treatment with high-flow oxygen should be implemented regardless of pulse oximetry or arterial PO2.Important details: Carbon monoxide poisoning is a diagnosis suspected by clinical history and confirmed by measurement of carboxyhemoglobin. Normal baseline carboxyhemoglobin levels ≤3% are seen in nonsmokers but may be up to 10% to 15% in smokers. Hyperbaric oxygen may be utilized if carbon monoxide level is >25% (20% if pregnant), pH is < 7.1, or there is loss of consciousness or concern for end-organ damage. Another common fire- or smoke-related toxicity is cyanide poisoning, which can further exacerbate cellular hypoxia.

Bottom Line: Carotid duplex ultrasonography is the preferred initial study for assessing blood flow through the carotid arteries.

true Carotid duplex ultrasonography is the most appropriate initial test for the workup of potential carotid disease and stenosis. The test requires no radiation and is relatively inexpensive. The limitations of the test include user dependence, inability to see soft atherosclerotic disease, limitation by heavy calcification, and body habitus limitation. The test does not involve the intracranial segments of the internal carotid artery. For evaluation of the bony covered segments, computed tomography (CT) or magnetic resonance angiography (MRA) should be considered.Of note, patients with transient visual loss do not need to be referred for head CT as a stroke would generally not cause transient phenomena, and ischemia is a rare cause of isolated transient visual loss. If there is a concern for vertebrobasilar ischemia (generally presents with other symptoms such as dizziness), then the test of choice is magnetic resonance imaging (MRI)/MRA because this is better able to evaluate the posterior circulation. Other tests to consider include erythrocyte sedimentation rate/C-reactive protein for giant cell arteritis, an ophthalmologic evaluation for fundoscopic exam, and consideration of Holter monitor/echocardiogram for cardiogenic sources of emboli. If there are other symptoms that raise concern for partial seizures, then an electroencephalogram (EEG) can be performed, and in patients with a history of thrombosis, hypercoagulable state testing can be added. MRI of the brain does not adequately visualize the intracranial vasculature for diagnostic purposes and is an inappropriate exam unless there were other symptoms consistent with posterior circulation ischemia.

The clinical presentation of this patient is consistent with chancroid caused by Haemophilus ducreyi. Chancroid is a sexually transmitted disease that presents with painful genital ulcerations. Fifty percent of the patients also present with painful inguinal lymphadenopathy with occasional bubo formation. Lymphadenopathy is usually unilateral and lymph nodes may rupture. Diagnosis can be made by PCR or by Gram stain that shows gram-negative rods, also sometimes described as "schools of fish" or "railroad tracks."

true Chancroid is a sexually transmitted infectious disease characterized by painful ulcers, bubo formation, and painful inguinal lymphadenopathy. It is caused by Haemophilus ducreyi. Remember the mnemonic "You DO cry with ducreyi."

Bottom Line: Alcoholic hepatitis is an acute inflammation of the liver triggered by heavy alcohol consumption in a short time period (binge drinking). Chronic alcohol use causes cirrhosis of the liver, which may present as abdominal pain, ascites, and jaundice. A complication of cirrhosis is portal hypertension, which results in dilated esophageal varices that can bleed, requiring immediate intervention.

true Chronic alcohol intake is one of the most common causes of cirrhosis in the United States. Cirrhosis results from chronic liver injury and is characterized by fibrosis of regenerating hepatocellular nodules, which can be seen on ultrasound as an irregular liver contour. Fibrosis and destruction of liver sinusoids result in a rise in the portal venous pressure and stimulate the development of a portosystemic collateralization. Esophageal varices are one of the most common presentations of portal hypertension. Other areas of collateralization include the epigastric venous system (caput medusa) and the hemorrhoidal venous plexus. Cirrhotic patients may also present with ascites, jaundice, and abdominal pain due either to direct inflammation of the liver or alternative associated conditions such as alcoholic gastritis or pancreatitis, portal hypertensive gastropathy, or spontaneous bacterial peritonitis.

A medial collateral ligament (MCL) tear occurs frequently in athletes whose sports involve sudden changes in direction and speed, as well as patients who are struck on the outside of the knee. Female athletes involved in soccer and basketball appear to have the highest prevalence of MCL tears. The MCL provides restraint against ----stress.

valgus

Bottom Line: Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) in acute pancreatitis still represents a substantial problem, with a mortality rate in the range of 30%-40%. Symptoms of ARDS come on suddenly, usually within hours or days of the event that initially caused injury to the lung. ARDS is defined by three main signs and symptoms: tachypnea, dyspnea, and hypoxia. Hypoxia can result in organ failure and symptoms such as rapid heart rate, abnormal heart rhythms, confusion, and extreme tirednessCOMBANK Insight : Once the patient is stable enough to be discharged from the hospital, routine clinical follow-up care (typically including physical examination and amylase and lipase assays) is needed to monitor for potential complications of the pancreatitis, especially pseudocysts.

true Complications of acute pancreatitis may include: acute kidney failure, acute respiratory distress syndrome (ARDS), ascites, cysts or abscesses in the pancreas, heart failure, and hypotension.

Hemochromatosis is a hereditary disease characterized by excessive absorption of dietary iron resulting in a pathological increase in total body iron stores. Early symptoms include severe fatigue (75%), impotence (45%), and arthralgias (40%). Skin bronzing (70%) occurs late in the disease process and reflects a combination of iron deposition and melanin. The classic triad of cirrhosis, diabetes mellitus, and skin pigmentation should be noted.

true Conn syndrome, also known as primary hyperaldosteronism, is an adrenal disorder characterized by the overproduction of aldosterone. Patients almost always present with hypertension (not hypotension as in the above case) and may also complain of muscle weakness or cramping in addition to headaches secondary to hypokalemia or increases in blood pressure.

Bottom Line: Apophysitis can mimic psoas syndrome.

true Correct answer: A Although the presentation seems straightforward,psoas syndromehas a variety of different causes and mimickers that must be considered. Musculoskeletal differentials include apophysitis and labral tears.The apophysis is a secondary ossification center that serves as the attachment site for a muscle-tendon unit. Apophysitis is the irritation of that ossification center. With repeated stress, an avulsion injury may occur at this location. Apophysitis occurs in active adolescents, and exercise-associated pain may be felt at any of the apophyses around the pelvis including the anterior superior iliac spine (ASIS), anterior inferior iliac spine, and inferior pubic rami. Tenderness is localized to the bony origins, rather than the tendons and muscles. In this young active patient with pain around the ASIS, apophysitis should be considered. Apophysitis can often be diagnosed with an x-ray and confirmed with an MRI, if necessary, although empiric treatment may often be enough. Treatment is often rest.

Timely orchiopexy for cryptorchidism may improve fertility and allow for more normal testicular development. It does not eliminate the risk of developing testicular cancer.

true Cryptorchidism is the absence of 1 or both testes from the scrotum. It is the most common birth defect of male genitalia. About 3% of full-term and 30% of premature infant boys are born with at least 1 undescended testis. Spontaneous descent is rare after 6 months, and surgical referral is imperative. Timely orchiopexy can allow more normal testicular development and potentially increase fertility

DiGeorge Syndrome (DGS) is now known to be associated with a chromosome 22q11.2 deletion syndrome. It generally will present within the first three days of life with low serum calcium levels, and often with seizures. The facies described in the question are classic for DiGeorge syndrome. These patients have impaired immunity related to their absence of a functional thymus. The size of the thymic shadow on imaging studies is unreliable though is commonly used in board questions to help with the diagnosis.

true DiGeorge syndrome is associated with an absent thymus, characteristic facies such as a small mandible and long facial features, and often hypocalcemia.

Bottom Line: The initial evaluation of patients presenting to the hospital for any reason should begin with focus history and physical examination.COMBANK Insight : Physical examination is almost always the answer for questions asking "What is the initial evaluation?"; just like always checking the "CABs" when approaching a trauma patient.

true Don't forget the basic physical examination. The initial evaluation of patients presenting to the hospital for labor includes a review of the prenatal records with focus on any antenatal complications, dating criteria, and a focus history and physical examination.

Bottom Line: A diet high in nitrates and salts is a risk factor for the development of gastric cancer.

true Gastric adenocarcinoma is the fifth most common malignancy worldwide. It commonly presents with the symptoms of weight loss and persistent abdominal pain. The weight loss is generally due to reduction in caloric intake rather than increased catabolism. In patients with proximal gastric cancer, the initial presenting symptom may be dysphagia due to esophageal obstruction. The incidence of gastric cancer has steadily decreased due to improvements in diet and the treatment of Helicobacter pylori. The etiology of gastric cancer is complex and multifactorial, but known risk factors include male gender, smoking, family history, diets high in nitrates and salts (eg, cured or processed meats and cheese), gastric polyps, previous gastric resection, H pylori infection, and chronic gastritis. Protective factors include aspirin usage, fresh fruit/vegetable consumption, selenium, and vitamin C. The diagnosis of gastric cancer is best made by upper gastrointestinal endoscopy, which can both visualize the exact location of the lesion and obtain tissue for pathology. If there is concern for metastatic or significant locally advanced disease, then a staging laparoscopy can be considered to evaluate for peritoneal metastasis (positron emission tomography scan is only 50% sensitive for peritoneal metastasis).

Bottom Line: If a patient becomes pregnant with an IUD in place, counsel her on the risks and benefits of removal and, if possible, remove the device by applying gentle traction on the string. In general, IUDs should be removed prior to 12 weeks. After this time frame, the risk of miscarriage increases.

true Patients who become pregnant with an IUD in place have an increased risk of spontaneous abortion, placental abruption, and preterm delivery. Because of this, if possible, the IUD should be removed by applying gentle traction on the string. Patients should be extensively counseled on the possibility of spontaneous abortion after IUD removal. In general, IUDs should be removed prior to 12 weeks gestation if possible. After 12 weeks, the risk of miscarriage after removal goes up.If the IUD cannot be removed by pulling the string or removed easily using either instruments under sonographic guidance or hysteroscopy, the device may be left in situ. The risks of pregnancy loss with aggressive attempts at IUD removal must be weighed against the risks of adverse maternal and fetal outcomes later in pregnancy, including infection and preterm delivery, if the device is left in place.

The two physical exam tests to know for diagnosing anterior cruciate ligament injuries are the Lachman test and the anterior drawer test. Both are performed in a similar fashion, which makes it easy to confuse the two. COMBANK Insight : Anterior cruciate ligament (ACL) injuries most commonly occur from non-contact injuries and are seen most commonly in young female athletes. Think ACL injury in a young female with immediate pain and swelling who lands awkwardly from a jump.

true Given the history and physical exam, the patient has an anterior cruciate ligament (ACL) tear. ACL injuries most commonly occur from non-contact injuries and are also more common in female athletes. A Lachman test is performed with the patient's knee flexed up to 15º and applying an anteriorly directed force on the proximal tibia. A positive test is greater than 3 mm of anterior tibial translation. It is important to test and compare both knees in every patient as some patients may have increased laxity or stiffness resulting in a false result. It is also important to make sure the patient does not have a posterior cruciate ligament injury resulting in a posterior sag of the proximal tibia and a false Lachman test. The Lachman test has been shown to be the most sensitive physical exam in the setting of acute ACL injuries.

Bottom Line: Patients who test positive for group-B strep (GBS) should receive ampicillin during labor at least 4 hours prior to delivery of infant. COMBANK Insight : Because of possible resistance with clindamycin, vancomycin remains the initial treatment of choice for group B streptococcal infection in patients who are allergic to penicillin and do not have susceptibility results.

true Group B streptococcal testing should be performed between 35 and 37 weeks gestation. Patients found to be positive should receive antibiotic treatment with IV penicillin or IV ampicillin at hospital admission or rupture of membranes. Generally, a smaller dose of antibiotic, for both ampicillin and penicillin, would then be repeated every 4 hours until delivery. If delivery occurs less than 4 hours following antibiotic therapy, a CBC and blood culture should be drawn and the child should be closely monitored for signs of sepsis. If a woman is allergic to penicillin and has a low risk for anaphylaxis, then a cephalosporin can be used such as cefazolin. Those with high risk or previous anaphylaxis can be treated with clindamycin (if susceptible) or vancomycin.

Bottom Line: Internal hemorrhoids present with painless anal bleeding. External hemorrhoids are associated with pain, anal bleeding, and pruritus.

true Hemorrhoids are most commonly due to excessive straining from constipation. External hemorrhoids are vascular-rich connective tissue cushions that are located in the anal canal distal/below the dentate/pectinate line. Symptoms include bright blood per rectum, anal pruritus and/or pain. The pain is due to thrombosis. External hemorrhoids are painful to touch and may be painful when defecating. Treatment includes sitz baths, high-fiber diet, and hydrocortisone cream. Thrombosed external hemorrhoids are treated with warm sitz bath, analgesics, lidocaine, and surgical excision or ligation.

Bottom Line: Hepatitis B is the most commonly transmitted infectious disease acquired during the transfusion of blood products.

true Hepatitis B remains the most commonly transmitted disease acquired during blood transfusion. Hepatitis B and C: The risk of having a donation that carries hepatitis B is about 1 in 205,000. The risk for hepatitis C is 1 in 2 million. If a patient receives blood during a transfusion that contains hepatitis, they will most likely develop the virus.

Bottom Line: If untreated, milk-alkali syndrome can lead to acute renal failure.COMBANK Insight : The timing in the measurement of PTH is critical. In milk-alkali syndrome, but not in other forms of hypercalcemia, vigorous treatment of hypercalcemia with saline diuresis and loop diuretics may lead to hypocalcemia. This occurs within the first few days of treatment and is associated with a suppressed PTH. However, with the hypocalcemia, PTH will rise and may reach levels above the reference range. PTH levels should be determined before or at the initiation of the treatment. If serum PTH is measured after the treatment is started, the levels are unpredictable and the results will be confusing.

true If untreated, milk-alkali syndrome can lead to the development of acute renal failure. Therefore, it is important to accurately make the diagnosis and place the patient on appropriate pharmacologic therapy. Bottom Line: Following fluid rehydration, patients with milk-alkali syndrome should undergo calciuresis with furosemide.COMBANK Insight : Loss of calcium from urine can be increased with the use of a loop diuretic, but this therapy cannot be started until intravascular volume has been replenished. Renal dialysis has been used in a few patients, as has an intravenous infusion of pamidronate.

Bottom Line: The tumor marker CA-125 can be elevated in a patient with endometrial cancer.COMBANK Insight : It is important to know tumor markers and their associated cancers for the COMLEX exam.

true In the initial diagnostic work-up for a patient with uterine cancer, you can order a CA-125 to evaluate for extrauterine disease. In endometrial cancer, it will be elevated, but extremely elevated levels usually indicate ovarian cancer. This lab value is also elevated in other cancers such as cancer found in the fallopian tube, colon, pancreas, breast, and lung. In reviewing for the COMLEX, it is best to associate this value with gynecologic cancers and specifically with ovarian cancer when extremely elevated.

Bottom Line: A cystic mass, unless it poses an impending threat to the mother's or baby's health, can be conservatively managed during pregnancy.

true In this case, the patient is asymptomatic and there is no threat to the health of the baby or the mother. The majority of women who are discovered to have adnexal masses during pregnancy can be managed conservatively, unless there is a risk of torsion, hemorrhage, or malignancy. This cystic mass is likely a functional ovarian cyst of benign etiology. In the absence of symptoms, management of simple nonsuspicious masses is left for after delivery.

Sheehan syndrome, or postpartum hypopituitarism, is a rare complication of severe postpartum hemorrhage. The pituitary gland is enlarged in pregnancy and is prone to infarction from hypovolemic shock. As a result, necrosis, atrophy, and scarring of the pituitary gland occur, leading to a nonfunctional gland with a decreased production of hormones. A common presentation is a failure to lactate and amenorrhea, but any of the manifestations of hypopituitarism can occur anytime from the immediate postpartum period to years after delivery. Treatment is lifelong hormone replacement therapy.

true Sheehan syndrome, ischemic necrosis of the pituitary gland, can occur after postpartum hemorrhage due to hypotension and can present days to years after delivery with symptoms such as amenorrhea and failure to lactate.

Landau-Kleffner syndrome (LKS) presents around 6 years of age with progressive loss of speech, hyperactive behavior, and seizures. EEG will show a bihemispheric spike and wave appearance. Seizures have a broad etiology, and common, life-threatening pathology should be ruled out first.

true Landau-Kleffner syndrome (LKS), also known as acquired epileptic aphasia, is a rare disorder that involves a progressive loss of speech around 3 to 6 years of age. Prior to this age, the child typically has normal growth and development. The disease involves a loss of higher cortical functioning and is believed to be a result of interruptions in the maturation of the temporal cortex. Other characteristic features of LKS include the occurrence of epileptiform seizures and hyperactive behavior. It is important to recognize the difference between LKS and autism; although the disease bears some resemblance to autism, there are important differences, such as age of onset. Autism occurs typically in the second year of life and is not commonly associated with seizure.While the diagnosis will ultimately be made by abnormal EEG findings, in this undifferentiated patient who presents with neurologic symptoms, the most important first step is to rule out immediately life-threatening brain pathology. A CT of the head without contrast is quick and accurate in ruling out brain hemorrhage, structural lesion with mass effect, and hydrocephalus. MRI can be considered but would cause unnecessary delay in ruling out emergent conditions, and CT of the head should be performed first.

Bottom Line: Patients with bulimia nervosa often suffer from laxative abuse in an attempt to promote weight loss.

true Laxative abuse is very common in patients with bulimia nervosa, and questions should be directed toward their use. Common laxatives include bisacodyl, cascara, senna, and high-fiber supplements. Abuse of stimulant laxatives can lead to severe constipation, due to their damaging effects on the myenteric plexus. Caffeine, pseudoephedrine, phenylpropanolamine, and synthroid may also be used to try to increase metabolic rate and calorie loss. Always question patients with bulimia regarding the use of natural herbal substances as these agents can have profound effects on heart rate and blood pressure.

Osmotic demyelination syndrome can occur with rapid correction of serum sodium, and treatment is largely supportive. MRI is the first-line diagnostic imaging test.

true MRI is the first-line diagnostic imaging test. This patient presents with known hyponatremia and was given multiple liters of 3% saline. Generally, very little hypertonic saline is needed to reverse the acute complications of hyponatremia, and giving more than needed can result in rapid overcorrection. A feared complication of overcorrection is osmotic demyelination syndrome, which can occur as a complication of severe and prolonged hyponatremia. It has been shown that correction of serum sodium of less than 8 mEq/dL within a 24-hour period has a decreased chance of causing osmotic demyelination syndrome. Once it occurs, treatment is largely supportive. Most patients end up with pontine demyelination, resulting in "locked-in" syndrome, a neurological condition in which the patient is able to move the eyes, but little else.MRI is the first-line test for detecting osmotic demyelination syndrome. If MRI is unavailable, a CT may be performed, but it is less reliable for detecting demyelinating lesions. It is important to note that the MRI may not become positive for up to 4 weeks after the rapid overcorrection of hyponatremia. Therefore, a negative test does not rule out osmotic demyelination syndrome, and a repeat MRI should be performed in several weeks.

Because the mother is suspected to have an infection (chorioamnionitis), she needs to have a vaginal delivery induced. A sterile speculum exam would be indicated if she had premature rupture of membranes without suspected infection.

true Magnesium sulfate is the treatment for severe preeclampsia or eclampsia neither of which is consistent with this case.

Bottom Line: Medicare is for those >65 years old, <65 years old with disabilities, or of any age with end-stage renal disease. Medicaid is for very-low-income families, the blind, people with qualifying disabilities, and some pregnant women and their infants often up to 1 year of life. The Children's Health Insurance Program (CHIP) provides low-cost health insurance to children whose families make too much for Medicaid but cannot afford private insurance.

true Medicaid is available to families with limited income, some pregnant women and their children, the blind, and people with other disabilities. Rules for income qualification vary from state to state, but if the family makes >$30,000 per year (for a family of 4), they will likely not be eligible. This patient is pregnant and makes only $20,000 a year, so she would easily qualify for Medicaid.

Laxative abuse may also be presented in a patient with an eating disorder.

true Melanosis coli is a benign disorder of pigmentation of the wall of the colon that is asymptomatic and often an incidental finding on colonoscopy. It is associated with the use anthraquinone laxatives such as senna.

Bottom Line: Onycholysis and nail pitting are common nail findings in patients suffering from psoriasis.

true Nail findings associated with psoriasis include onycholysis, oil spots, and nail pitting. Onycholysis refers to the painless separation of the nail from the nailbed and is a common finding, along with nail pitting, in patients suffering from psoriasis. Onycholysis appears as a white area of the nail plate due to a functional separation of the nail plate from its underlying attachment to the nail bed. Typically, the defect begins distally and progresses proximally, causing a traumatic uplifting of the distal nail plate.

Since the patient has a 3cm laceration she has a type 2 fracture and needs treatment with a first generation cephalosporin. Since she is allergic to penicillin, clindamycin should be used as an alternative.

true Open fractures are classified according to the characteristics of the open wound and treatment is based on that classification. Type II open fractures are treated with a first generation cephalosporin. If an allergy exists to cephalosporins then clindamycin may be used as an alternative.

Bottom Line: Comfort at rest and fatigue with minimal exertion is NYHA Class III.

true The NYHA functional classification system for congestive heart failure places patients in one of four classes of heart disease, based on the presence or absence of physical limitation. Classes I-IV are described in the table here. The patient in this case, who was previously placed in Class I, has progressed to the status of Class III, or moderate, congestive heart failure, which would alter his management significantly.

A male smoker over age 65 with no prior screenings and a greater than 30-pack-year history needs colorectal screening, an abdominal ultrasound, and a low dose CT.

true The USPSTF recommends against screening for COPD in asymptomatic adults. who are smokers and may have COPD

This patient has severe 3-vessel coronary artery disease and severe left ventricular systolic dysfunction. Such patients (regardless of symptoms) should undergo revascularization for mortality benefit. Moreover, patients with diabetes mellitus and multivessel coronary artery disease generally should be strongly considered for surgical revascularization as opposed to multiple stents. Regardless of revascularization, medical therapy is very important. Starting a statin is paramount in this patient. All patients with atherosclerotic cardiovascular disease should be started on statins.Finally, because he remains symptomatic despite optimal medical therapy and euvolemia, adding spironolactone would be reasonable at this time since his Cr < 2.5 and K < 4. Remember, spironolactone has a heart failure dose (12.5mg-25mg) which is quite small and a diuretic dose, generally used in the setting of ascites (100mg-400mg) which is quite large. The heart failure dose of spironolactone will not cause significant diuresis. It is a weak blood pressure lowering agent, which is why it is usually not recommended as first line therapy and 12.5 of spironolactone would be unlikely to cause any significant changes in blood pressure. true

true Patients with multivessel CAD and a low ejection fraction should undergo CABG. Primary prevention ICD implantation in heart failure patients should wait > 40 days after MI or > 90 days after revascularization (with optimal medical therapy) to ensure the ejection fraction is still less than 35%.

Bottom Line: Chronic marijuana use results in amotivation, conjunctival injection, a slowed sense of time, increased appetite, social withdrawal, hallucinations, and dry mouth. Its sweet odor may also be detected on the clothes of a patient.COMBANK Insight : When studying the effects of drugs of abuse, don't forget to review the signs/symptoms of withdrawal. In many cases, we have seen questions containing mixed answer choices consisting of both withdrawals and toxicities. It is not uncommon to see these.

true Persistent marijuana use causes "amotivational syndrome" (laziness and a lack of motivation), a slowed sense of time, and eating binges during intoxication. Patients may also exhibit conjunctival injection, hallucinations, social withdrawal, and dry mouth. Marijuana also has a very distinct smell, which can potentially be detected on a patient's clothes.

This question asks you to know the difference between incidence and prevalence, an important distinction in epidemiologic studies. Prevalence indicates the number of existing cases in a population at a specific time. In this study, the prevalence of disease when the researchers arrive is 236/100,000. Incidence reflects the occurrence of new cases of the disease, reflecting the rapidity with which newly diagnosed cases develop. The incidence rate can be calculated as a fraction with the number of new cases of disease during a specified time interval as the numerator and the summed person-years of observation or average population during the specified time interval as the denominator. To understand the difference, consider a highly virulent plague that spreads rapidly and kills quickly. This plague would have a high incidence, with many new cases each day, but a stable overall prevalence, since new cases die quickly and the total number of patients in the population does not increase. A chronic disease like diabetes, however, has a high prevalence, with many people diagnosed in the population, but a lower incidence, with fewer new cases being diagnosed per unit time. In this village, there are 16 cases per 100,000 people in 1 year. In other words, 16 cases per 100,000 person-years, or 0.16 cases per 1000 person-years.

true Prevalence is the number of existing cases in a population. Incidence is the number of new cases that develop over a period of time.

Ingestion of contaminated waters in the wilderness is a common risk factor for giardiasis, which may present with nonbloody diarrhea, steatorrhea, abdominal pain, or weight loss.

true Primary treatment options include nitazoxanide, tinidazole, or metronidazole. This patient has a significant risk factor from exposure to giardia lambia in the water of streams in the wilderness.

Fetal and neonatal risks are directly correlated to maternal control of hyperthyroidism. The most common manifestations of uncontrolled or poorly treated maternal hyperthyroidism are intrauterine growth retardation, prematurity, low birth weight, and stillbirth.

true Propylthiouracil (PTU) is the first-line treatment for hyperthyroidism in pregnancy during the first trimester. Methimazole is used after the first trimester.

Bottom Line: Rett syndrome is a disorder that predominantly affects females and is characterized by previously appropriate cognitive development with a regression (which is often rapid) of oral and motor skills. This regression typically occurs around 1-4 years of age.COMBANK Insight : Developmental disorders are high yield for COMLEX Level 3. The pediatric section is also heavy in understanding milestones, vaccination schedules, and childhood infections.

true Rett syndrome is characterized by the loss of some oral and motor skills. Patients may initially develop at a normal rate, or they may show subtle signs of developmental delay. Patients are almost exclusively female. Classically, there are four stages of the syndrome. Stage 1 (developmental arrest) occurs around 6-18 months of age and is characterized by vague symptoms, such as lack of interest, decreased eye contact, and hypotonia. Stage 2 (regression) may occur quickly or insidiously around ages 1-4 years and is described as autistic-like with loss of oral communication and purposeful hand movements. Stage 3 (pseudo-stationary) occurs around ages 2-10 years and is characterized by some improvement in hand and language skills; however, mental impairment persists, and seizures may occur. Stage 4 (late motor deterioration) is typically from 10 years and older. The patient does not experience any further decline in motor or oral skills; however, other motor issues occur (i.e., hypertonia, Parkinsonism symptoms, etc.).

Commonly implicated medications have some kind of anticholinergic effect, such as diphenhydramine, amitriptyline, or oxybutynin. this medications can affect cognition

true Schizophrenia is diagnosed by the criteria laid out in the DSM V. This criteria are divided into 5 categories. The first category requires two or more of the following: delusions, hallucinations, disorganized speech, disorganized or catatonic behavior, negative symptoms. They should generally have decline in their level of functioning. The symptoms should persist for at least 6 months. Major mood disorders need to be ruled out, including major depression and substance abuse should be ruled out as a cause.

Hysteroscopy is the gold standard test for the diagnosis of Asherman syndrome.COMBANK Insight : Asherman syndrome is the most common anatomic cause of secondary amenorrhea and remains a popular topic on COMLEX. It is almost certain that you will have questions dealing with the work-up of amenorrhea (both primary and secondary), as this is one of the major areas of gynecology tested on the exam.

true Secondary amenorrhea following a miscarriage requiring dilation and curettage (D&C) is Asherman syndrome until proven otherwise. The gold standard test to confirm this diagnosis is hysteroscopy.

Melatonin may benefit daytime sleep in shift work sleep disorder.

true Shift work sleep disorder (SWSD) is a circadian rhythm sleep disorder characterized by insomnia and excessive sleepiness that affects people whose work hours overlap with the typical sleep period. Sleepiness manifests as a desire to nap, unintended dozing, impaired mental acuity, irritability, reduced performance, and accident proneness. Shift work is often combined with extended hours of duty, so fatigue can be a compounding factor. Insomnia is the complaint of inadequate sleep; it can be classified according to the nature of sleep disruption and the duration of the complaint. Insomnia is subdivided into difficulty falling asleep (sleep onset insomnia), frequent or sustained awakenings (sleep maintenance insomnia), or early morning awakenings (sleep offset insomnia), although most insomnia patients present with 2 or more of these symptoms. Disruption of the normal circadian rhythm because of shift work at night results in decreased levels of melatonin. Melatonin is a naturally occurring hormone secreted by the pineal gland that acts at specific receptors in the central nervous system to produce both sedative and circadian phase-shifting ("chronobiotic") effects. Its effects on the circadian clock are opposite those of light, so it offers an advantage over other therapies in the management of SWSD.

Bottom Line: Smoking increases the risk of carcinoma of the lung, esophagus and oral cavity, larynx, pharynx, bladder, kidney, cervix, vulva, penis, anal cavity, and last, but not least, pancreas.COMBANK Insight : Patients typically report the gradual onset of nonspecific symptoms such as anorexia, malaise, nausea, fatigue, and mid-epigastric or back pain. Significant weight loss is a characteristic feature of pancreatic cancer.

true Smoking is the most common independent environmental risk factor associated with pancreatic cancer. Current data suggest that patients who smoke have a 2-fold increased chance of developing pancreatic cancer.

true Some of the lowest risk factors for the development of pancreatic cancer are alcohol use (>4 drinks per day), BMI >30, diabetes mellitus >5 years, family history of pancreatic cancer in a first degree relative, and tobacco abuse. These increase the risk less than fivefold. Higher risk conditions include chronic pancreatitis and cystic fibrosis as well as having 2 or more first degree relatives with pancreatic cancer. The highest risk groups include patients with more than 3 relatives with pancreatic cancer, hereditary pancreatitis, and Peutz-Jeghers syndrome. Other hereditary conditions include multiple endocrine neoplasia, Lynch syndrome, and Von Hippel-Lindau among others. Peutz-Jeghers syndrome (PJS) is an autosomal dominant disorder associated with the development of hyperpigmented macules on the lips and oral mucosa as well as benign hamartomatous polyps throughout the GI tract. It is associated with a 10-15x increased risk of GI, lung, and gonadal malignancies and confers the highest increased risk of the factors listed above. Patients with PJS generally have a mutation in the STK11/LKB1 gene and molecular testing is available. Due to increased risk of cancer, these patients should have increased monitoring for malignancy.

Kidney stones <5 mm in diameter can pass through the ureterovesicular junction and should be allowed to be passed by the patient.

true Stones that are not treatable with ESWL can be treated with percutaneous or open nephrolithotomy or retrograde ureteroscopy.

This patient is presenting with acute rhinosinusitis, which is likely viral in origin. He has no symptoms which would be concerning for bacterial rhinosinusitis. The treatment for viral rhinosinusitis involves supportive care with numerous over the counter medications, most of which are noted above. These include the use of oral analgesics, intranasal sprays (glucocorticoid, saline, anticholinergic, and decongestant) as well as oral decongestants, antihistamines, and expectorants. There is no indication for the use of antibiotics or imaging in cases of acute viral rhinosinusitis. Current criteria for the presumptive (many of these cases may still be viral) diagnosis of acute bacterial rhinosinusitis (ABRS) include persistent symptoms lasting more than 10 days without any evidence of clinical improvement or a biphasic illness pattern which is also called double worsening, meaning the patient was sick, improved, and then became sicker a second time within a short time frame, usually within a 10 day period. The IDSA guidelines from 2012 also recommend the use of a high fever >39C associated with severe symptoms for 3-4 days as being more consistent with bacterial rhinosinusitis. According to the guidelines by the American Academy of Otolaryngology-Head and Neck Surgery published in 2015, fever itself early in the course of illness is not sensitive or specific enough to warrant treatment based on this vital sign alone, and they do not recommend using this as criteria for the diagnosis of ABRS. They agree with the other criteria used by the IDSA and acknowledge that a "severe" presentation may warrant the use of antibiotics as recommended by the IDSA and the American Academy of Pediatrics which considers more than 3 days of high fever and purulent nasal discharge as a severe presentation of ABRS in children.

true Summary Criteria for the Diagnosis of ABRS Signs or symptoms of acute rhinosinusitis present for 10 days or more after symptom onset with no improvement Acute worsening of improving rhinosinusitis within 4-6 days of symptom onset or "double-sickening." Severe rhinosinusitis: onset of high fever > 39C and severe symptoms within 3-4 days of onset Bottom Line: Acute rhinosinusitis can be diagnosed as "presumed" bacterial rhinosinusitis if the patient has symptoms for more than 10 days, double-sickening, or a severe presentation with high fevers.

Autonomic neuropathy is most common in long-term diabetes. However, other less common causes include autoimmune diseases where antibodies attack the nervous system such as lupus, rheumatoid arthritis, Sjögren syndrome, and Guillain-Barré. Infectious causes, such as Lyme disease can also cause autonomic neuropathy.

true Symptoms can include dizziness with syncope, urinary problems, impotence, and exercise intolerance.

Bottom Line: Systemic Juvenile idiopathic arthritis (JIA) presents with daily fevers, arthralgias, and rash. The diagnosis is one of exclusion. ANA and RF are generally negative, but Ferritin levels greater than 1000 (even ≥50,000 ng/mL) can help to make the diagnosis.

true Systemic Juvenile Idiopathic Arthritis (JIA), previously known as Still's disease, presents with daily fevers, arthralgias, and rash. Diagnosis is one of exclusion. The fever must be present for at least two weeks and the arthritis for at least six weeks in order to make a definitive diagnosis according to the International League ofAssociations for Rheumatology. Laboratory findings include leukocytosis, thrombocytosis, elevated ESR, hyperferritinemia, mild anemia, and mild increases in LFTs. ANA and RF are typically normal. UA is also typically normal. The hyperferritinemia can be helpful in diagnosis as there are very few other juvenile illnesses that are associated with a high ferritin.

Bottom Line: Men age 65 to 75 years old who are current or former smokers should be screened for abdominal aortic aneurysm with abdominal ultrasound.

true The abdominal aortic size varies with age, sex, and body habitus, but in general, 3.0 cm is considered aneurysmal in most adult patients. Abdominal aortic aneurysms (AAAs) most often affect the segment of aorta between the renal and inferior mesenteric arteries (infrarenal).Atherosclerosis is the leading cause of aneurysm formation in the abdominal aorta. Age, male sex, smoking, hypertension, and hyperlipidemia are the most common risk factors. Although AAAs are less common in females, women tend to rupture at smaller aortic diameters than men.Screening studies show that AAA occurs in up to 13% of men and 6% of women over the age of 65 years. AAAs are frequently found incidentally during either screening or other imaging studies. The palpation of a pulsatile mass is an ominous finding and not frequently encountered during early stages.Because the AAA may compress adjacent structures, patients may present with abdominal pain, chronic flank or back pain, or even ureteral obstruction. Patients who present with free rupture are acutely ill with hypotension, lactic acidosis, shock, and ultimately death. The US Preventive Services Task Force (USPSTF) supports one-time screening by ultrasonography for AAA among men age 65 to 75 years old who are current or former smokers.

Bottom Line: Duodenal atresia has the classic sign of a double bubble on ultrasound and is associated with Down syndrome.

true The beta-human chorionic gonadotropin (β-hCG) and inhibin are increased and the alpha-fetoprotein (AFP) and estriol are decreased on quad screen in Down syndrome. A quad screen is a blood test that is done in the second trimester between the gestational age of 15 and 20 weeks. The detection rate for Down syndrome is 81% using this test alone.

The electrocardiogram (ECG) in this exhibit is consistent with Wolff-Parkinson-White (WPW) syndrome. Atrial fibrillation, in the setting of WPW, can lead to sudden cardiac death. WPW is fairly rare, occurring in 0.3% of the population. Approximately 20% to 50% of these patients will develop some type of tachyarrhythmia and, rarely, sudden death, secondary to accelerated ventricular rates. Patients with WPW have a short P-R interval as conduction from the atria to the ventricle is through an accessory pathway, also known as the bundle of Kent. This route bypasses the atrioventricular (AV) node, which normally slows conduction to allow for a minimum time of ventricular filling. With very short refractory periods and no brake on conduction, it is possible for atrial arrhythmias such as atrial fibrillation or atrial flutter to conduct through the accessory pathway and activate the ventricle using 1:1 conduction. Rates in the atria can be as high as 300 beats/min for atrial fibrillation, which, at 1:1 conduction, can result in complete loss of cardiac filling time and a near complete loss of cardiac output. This is why atrial fibrillation, in the setting of WPW, can lead to sudden cardiac death. The treatment of WPW is with catheter ablation for symptomatic patients or asymptomatic patients with cardiac risk factors (coronary artery disease, atrial fibrillation, congenital cardiac malformations, cardiomyopathy, or valvular disease).

true The cause of death in WPW is rapid conduction through the accessory pathway resulting in unstable ventricular rates and decreased cardiac output.

A child who goes to day care and presents with high fever and bloody diarrhea is likely suffering from Shigella

true The clinician should rapidly assess the patient's fluid and electrolyte status and institute parenteral or oral hydration, along with antipyretics as needed. Prompt recognition and treatment of seizures and raised intracranial pressure are essential. Nutritional supplementation of vitamin A (200,000 IU) can hasten clinical resolution in malnourished children.

Bottom Line: Cost-effectiveness analysis is usually expressed in dollars per quality-adjusted life-year, or the additional cost to society to increase life by 1 year of perfect health.

true The cost-effectiveness ratio is an estimate of the additional cost to society to increase population health by 1 year of perfect health. In this scenario, to save 1 year of quality health, societal costs would be over $15,000.

true The finger-to-nose test is one of many tests used to check normal function of the cerebellum. Abnormal findings include intention tremor, dysmetria, and dysdiadochokinesis.

Bottom Line: Pharmacotherapy can and should be used to treat depression in pregnant patients, especially if they have a history of depression or were on pharmacotherapy before pregnancy.

true The most likely diagnosis in this patient is severe major depressive disorder given this patient's complaints of down mood and anhedonia as well as her new complaints of suicidal ideation with a concrete plan. Anytime a patient has devised a plan to commit suicide, immediate treatment is indicated, especially in a pregnant patient since there is risk not only to the mother, but also to the fetus. This patient has recognized her depression and is willing to undergo treatment; however, she wants to avoid any potential risk to her unborn child. Although the treatment of depression in pregnancy appears difficult, and very few randomized studies have been performed to verify the general safety and tolerability of selective serotonin reuptake inhibitors (SSRIs) during pregnancy, it does appear that the risks are quite low, especially when compared with the risks of untreated depression, including poor nutrition, mood, and possible suicide. It is generally recommended that if a woman with a history of depression was previously treated successfully with a particular antidepressant or psychotherapy, that they be treated again with the same. In this case, her previous history of successful treatment with citalopram indicates that would be the correct choice for initial pharmacotherapy. When initiating pharmacotherapy, it is generally started at the lowest therapeutic dose, especially if given within the first trimester; however, if higher doses were previously required, it may be better to start at the higher dose given the risk of undertreatment. There is no evidence that lower doses decrease the risks of adverse fetal outcomes. There is evidence that stopping antidepressants during pregnancy leads to relapse of depressive episodes.

A lateral collateral ligament (LCL) injury is uncommon, and is more prevalent in motor vehicle accidents. This injury results from an extreme varus stress, and patients complain of pain over the lateral joint line and lateral aspect of the knee. The pain or laxity associated with an LCL tear is aggravated by a -----stress test.

varus

Sjogren's syndrome is characterized by dry mouth, dry eyes, arthritis, and parotid enlargement and is associated with autoantibodies (Anti-Ro and Anti-La).

true The most likely diagnosis is Sjogren's syndrome. Sjogren's syndrome has a classic triad of xerophthalmia, xerostomia, and arthritis. In this patient, the sensation of dirt in her eyes is a manifestation of dry eyes and is a common patient complaint. Sjogren's is associated with parotid enlargement (the facial swelling this patient is describing), increased risk of non-Hodgkins B cell lymphoma, and dental caries. Caries are present in this patient due to the loss of saliva which is protective against the overproduction of oral bacteria.Patients with Sjogren's may have autoantibodies to nuclear antigens including SS-A (Ro) and SS-B (La). These conditions predominately affect women between the ages of 40 and 60. Sicca syndrome is a term for dry exocrine glands and can be caused by a large variety of conditions, including drug effect. In this question, Benadryl is likely exacerbating her underlying disease, but would not be expected to cause a positive SS-A or be associated with parotid enlargement and dental caries. Medications that exacerbate Sjogren's syndrome should be stopped, and medications to help with lubrication will need to be started, including artificial tears or punctal plugs. For dry mouth, artificial saliva can be used, and pilocarpine can be added for patients who fail treatment.

Ultrasound and MRI are the best imaging tests to confirm a Baker cyst. Ultrasound is the best initial workup after radiographs due to cost, time, and availability.COMBANK Insight : COMLEX questions will commonly make you think about which test is the most appropriate for a given situation. Even if you don't automatically know the answer, you should be able to use the process of elimination to narrow down the choices to one or two.

true The most likely diagnosis is a Baker cyst (popliteal cyst), which is a benign swelling commonly associated with chronic arthritis. The cyst is filled with synovial fluid and usually maintains a direct connection with the joint cavity. If the cyst bursts it can cause pain, swelling, and redness. Ultrasound and magnetic resonance imaging are the best imaging tests to confirm a Baker cyst. Ultrasound should be the best next exam because of its low cost, speed, and ability to image dynamically. It can help differentiate a Baker cyst from other conditions, such as a popliteal aneurysm, ganglion cyst, or popliteal mass. Additionally, plain radiography can demonstrate joint or bone changes that may be associated with the formation of a Baker cyst.Baker cysts are thought to be caused by increased pressure inside the joint, which causes the synovium to protrude through weak areas in the knee capsule. A Baker cyst usually does not require treatment unless it is symptomatic. Initial treatment includes rest and elevation, with use of ibuprofen or acetaminophen for pain control. Further treatment involves draining of the cyst with local injection of corticosteroid to reduce inflammation. Surgical excision is reserved for severe cases.

Bottom Line: The new classification criteria published by the American College of Rheumatology in 2010 aimed to diagnose rheumatoid arthritis earlier in patients, and thus, the criteria no longer include symmetric arthritis, rheumatoid nodules, or radiographic changes (all of which are unlikely to be seen early in the disease).

true The most likely diagnosis is primary biliary cirrhosis (PBC). PBC involves granulomatous destruction of the intrahepatic ducts within the portal triads without affecting the extrahepatic ducts. It is an autoimmune disorder that mainly affects middle-aged women and can increase the risk of developing hepatocellular carcinoma. Ursodeoxycholic acid has been shown to slow the progression of the disease, whereas cholestyramine can be used to relieve pruritis along with diphenhydramine. Liver transplantation improves survival to 70% at 10 years. Laboratory findings include increased alkaline phosphatase, increased bilirubin, increased cholesterol, positive antimitochondrial antibodies, increased GGT, and increased serum IgM.

Hypertension, cocaine use, trauma, extremes of age, smoking, previous history of placenta abruption, and thrombophilia are some well-known risk factors for placental abruption.

true The only significant risk factor in this patient's presentation for placental abruption is smoking. The exact mechanism or connection between smoking and placental abruption is not known; however, it is felt to be due to placental ischemia secondary to the vasoconstrictive affects of tobacco, resulting in necrosis and hemorrhage and eventual placental separation. Smoking is associated with a 2.5-fold increase in the risk of placental abruption, and that risk increases by 40% more for each pack per day smoked. Additional risk factors for placental abruption include history of placental abruption (this is the highest risk), followed by cocaine and drug use, followed by eclampsia and preeclampsia and chronic hypertension. The treatment of hypertension does not modify the risk for placental abruption. Smoking is one of the only modifiable risk factors.

Bottom Line: Right supraclavicular adenopathy is usually associated with cancer in the mediastinum, lungs or esophagus whereas left supraclavicular adenopathy suggests an abdominal source, such as stomach, gall bladder or pancreas.

true The patient above presents with weight loss and supraclavicular lymphadenopathy. Supraclavicular lymphadenopathy is associated with a high risk of malignancy. Right supraclavicular adenopathy is usually associated with cancer in the mediastinum, lungs or esophagus whereas left supraclavicular adenopathy (known as Virchow's node) suggests an abdominal source, such as stomach, gall bladder or pancreas. Given this patient's history and exam finding, the most likely diagnosis is gastric cancer. Gastric tumors are more common in those of Asian ethnicity. Classically, gastric tumors present with iron deficiency anemia with abdominal pain in the elderly. Risk factors include diet high in smoky or salted foods, helicobacter pylori infection, pernicious anemia, chronic gastritis and smoking. "Red flag" signs that should increase suspicion for gastric cancer include blood in the stool, abdominal pain, and significant unintentional weight loss.

Bottom Line: When a medical error occurs, it is in the best interest of all parties to immediately and fully disclose all information with the patient and the family.

true The patient and the family should be made aware of the error immediately, and all information pertaining to the incident should be fully disclosed. Additionally, the physician or surgeon should be the one who initiates the conversation regarding the medical error.

The CT findings of an epidural hematoma are a biconvex or lentiform mass that displaces the brain away from the calvarium and does not cross suture lines.

true The patient described here presents with an epidural hematoma (EDH) and rapidly deteriorating level of consciousness. In cases of an acute EDH and signs of brain herniation, the patient should be prepared for emergent craniotomy in order to reduce intracranial pressure. In the operating room, a skin incision is made to allow for the removal of a bone flap that overlies the hematoma; the hematoma can then be evacuated and the bleeding source can be identified and coagulated.

In a patient with sudden-onset muscle weakness and aches in the absence of sensory loss or recent illness, always check medications for possible statin-induced myopathy.

true The patient in the scenario presents with statin-induced myopathy. Simvastatin is used in the treatment of hyperlipidemia, and statin-induced myopathy presents as muscle aches and weakness that can progress quickly over the course of several months. The weakness can be severe enough to require the use of a wheelchair. Myopathy, if unrecognized, can progress to rhabdomyolysis, characterized by very high levels of the muscle enzyme creatine kinase. Myopathy can present with symptoms such as excessive fatigue, postexertion aches, or fixed weakness such as the inability to rise from a chair to a standing position. Sensation, reflexes, and bowel and bladder function are preserved. Cessation of simvastatin is the treatment.

Bottom Line: Negative symptoms are associated with disruptions to normal emotions and behaviors. These symptoms are harder to recognize as part of the disorder and can be mistaken for depression or other conditions. These symptoms include the following: flat affect, a lack of pleasure in everyday life, lack of ability to begin and sustain planned activities, and speaking little, even when forced to interact. People with negative symptoms need help with everyday tasks, often neglect basic personal hygiene, and have poorer response to medical therapy.COMBANK Insight : Primary and enduring negative symptoms are often referred to as the "deficit syndrome." Individuals with the deficit syndrome have been found to have greater cognitive deficits and poorer outcomes than patients who do not have this syndrome.

true The patient most likely has schizophrenia, which commonly presents in the late twenties or early thirties. Positive symptoms are those that most individuals do not normally experience but are present in people with schizophrenia. Positive symptoms include delusions; disordered patterns of thought; and tactile, auditory, visual, olfactory or gustatory hallucinations. Hallucinations are also typically related to the content of the delusional theme. Positive symptoms generally respond well to medication. This is because medications target these symptoms best. It can be treated with dopamine antagonists.Earlier age of onset of symptoms, no precipitating stressors, and negative symptoms lead to a poorer response to medical therapy. Negative symptoms include a flat expression or little emotion, poverty of speech, inability to experience pleasure, lack of desire to form relationships, and lack of motivation. These elements contribute more to a poor quality of life, functional ability, and burden on others than do positive symptoms. People with greater negative symptoms often have a history of poor adjustment before the onset of illness, and response to medication is often limited.

The right recurrent laryngeal nerve is the most common nerve injured during thyroidectomy.

true The recurrent laryngeal nerve is a branch of the vagus nerve that supplies motor function to, and sensory information from, the larynx. Unilateral vocal cord paralysis is one of the primary complications of thyroidectomy due to its anatomic relationship to this nerve in the neck. If asked, the right recurrent laryngeal nerve is more susceptible to injury over the left because of its medial location.

Bottom Line: The treatment of choice for rheumatic fever is penicillin. Penicillin should be continued until adulthood with the goal of preventing recurrent rheumatic fever.

true The treatment of choice is penicillin. Other treatments include amoxicillin, cephalosporin, and macrolides. Treatment should be administered when the patient presents with streptococcal pharyngitis to prevent scarlet fever or rheumatic fever, and is one of the main reasons that young patients with streptococcal pharyngitis are treated so aggressively with antibiotic therapy. Prophylactic penicillin should be continued until adulthood with the goal of preventing recurrent rheumatic fever and worsening heart disease. Other sequelae of Streptococcus pyogenes infection include scarlet fever and poststreptococcal glomerulonephritis. It is notable that antibiotic treatment will not prevent the development of glomerulonephritis. Untreated, rheumatic fever can lead to complications such as mitral valve stenosis or regurgitation, which may require valvular replacement.For your information. This is unlikely to be tested:The duration of penicillin prophylaxis in rheumatic fever depends on whether or not there is underlying heart disease. If there was evidence of carditis and heart disease is present, penicillin should be continued for at least 10 years or until age 40, whichever is longer (in some cases lifetime, but this is beyond the scope of your exam). If there is carditis but no heart disease, then it will be continued for 10 years or until 21, whichever is longer. If there is no evidence of carditis, but the patient had rheumatic fever, then penicillin should be continued for 5 years or until age 21, whichever is longer.

Bottom Line: Muscle energy is a direct and active technique, meaning it engages a restrictive barrier and requires the patient's participation for maximal effect. As the corrective forces used come from both the patient and extrinsic to the patient (the physician in this case), it is further classified as both intrinsic and extrinsic.

true The video exhibit demonstrates the use of the muscle energy technique. Muscle energy is a direct and active technique, meaning it engages a restrictive barrier (ie, direct) and requires the patient's participation for maximal effect as the patient performs an isometric contraction (ie, active).The muscle energy technique involves corrective forces that are described as both extrinsic and intrinsic corrective forces. The physician applies an extrinsic counterforce during the patient's isometric contraction. Extrinsic forces are not limited to the patient or physician (ie, an extrinsic force could be gravity). An example of an intrinsic force used during muscle energy technique would include the patient's muscle contraction.

The management of multiple injuries requires recognition of management priorities with the goal of the initial assessment to determine the injuries that may threaten the life of the patient. The primary survey should include the ABCDEs: check airway, breathing, circulation, disability, and exposure: Airway: If obstructed, consider chin lift/jaw thrust, suction, nasopharyngeal airway, intubation. If intubation is necessary, keep the neck immobilized in a neutral position.Breathing: Assess breathing adequacy. If inadequate, consider artificial ventilation, decompression and drainage of pneumothorax or hemothorax, and closure of open chest injury.Circulation: If inadequate, stop hemorrhage and establish 2 large-bore intravenous (IV) lines. Administer fluids.Disability: Rapid neurologic assessment using Glasgow Coma Scale.Exposure: Search for injury. This includes in-line immobilization if neck or spinal injury is suspected. There is always a chance of cervical spine bone damage with any type of collision injury. The cervical spine must be cleared before a collar is removed. In order to clear a cervical spine, the patient must be awake and alert, not under the influence of any substance, have negative imaging of the cervical spine, and have a normal physical exam. There are 6 types of strains that can occur at the sphenobasilar synchondrosis (SBS): flexion/extension, torsion, sidebending/rotation, vertical strain, lateral strain, and compression. The osteopathic findings stated in the question describe compression. This type of strain occurs when the sphenoid and occiput have been pushed together. As a result, there will be a decrease in the amplitude of the flexion and extension components of the cranial rhythmic impulse (CRI). If the compression is severe enough, the CRI can be almost completely diminished. It can be due to trauma to the back of the head.

true There is always a chance of cervical spine bone damage with any type of collision injury. Cervical spine imaging is crucial!

Treat chemical reactive conjunctivitis with reassurance.

true These newborns will recover on their own in 24 to 48 hours without intervention.

Bottom Line: Ultrasound of the carotids can quantify the extent of carotid stenosis when a patient experiences a TIA or has an audible bruit.

true This patient had a transient ischemic attack (TIA) and now has the findings of a new carotid bruit on physical exam. Duplex ultrasound can be helpful to evaluate for carotid stenosis, which is a common cause for TIA and may need surgical correction. The presence of a bruit should further raise your suspicion for stenosis in the carotid artery. If ultrasound is not available or there is concern for stenosis of the carotid artery within the skull, CT angiography or magnetic resonance angiography may be used.Modifiable risk factors for developing a TIA and subsequent stroke, which is the basis of treatment, include coronary artery disease, obesity, atrial fibrillation, carotid stenosis, hypercholesterolemia, smoking, hypertension, diabetes and drug use. Non-modifiable risk factors include family history, age over 60 years old, male gender and non-white ethnicity. If this patient was found to have a blockage of 70% or more referral to a vascular surgeon would be appropriate.

Bottom Line: Dilated cardiomyopathy is seen is alcoholics with evidence of systolic dysfunction and should be addressed by immediate cessation of alcohol.COMBANK Insight : Alcoholic cardiomyopathy can be a result of direct toxic effect or due to thiamine deficiency.

true This patient has a diagnosis of dilated cardiomyopathy secondary to alcohol abuse. Unlike the hypertrophic and restrictive forms of the disease (which result in diastolic dysfunction), dilated cardiomyopathy results in systolic dysfunction from severe ventricular dilation. The strength of muscle contraction is represented by the Frank-Starling relationship in which muscle contraction is dependent on stretch. However, beyond a certain point, stretch becomes detrimental, and muscle contraction decreases. Ventricular dilation limits the strength of cardiac muscle contraction and results in a lowered ejection fraction. Although in many cases there is no identifiable cause for this disease, identifiable etiologies do exist, such as alcohol use, beriberi, Coxsackie B virus, Chagas disease, cocaine use, doxorubicin, and HIV. The patient in the above case has alcoholism, and the treatment is to stop drinking because alcohol is a direct myocardial toxin. Alcohol-induced cardiomyopathy is almost completely reversible by removal of alcohol. Symptoms are managed by medical therapy and measures to keep the patient compensated regarding heart failure.

Bottom Line: Initial evaluation of suspected gastric carcinoma should include an esophagogastroduodenoscopy to evaluate for mass and allow for subsequent biopsy of a lesion.

true This patient has a history of smoking and alcohol abuse, anorexia and weight loss along with the finding of left supraclavicular adenopathy which is highly suggestive of gastric cancer. Initial evaluation should include an esophagogastroduodenoscopy to evaluate for a mass and allow for subsequent biopsy of the lesion.

Bottom Line: Alcoholic hallucinosis occurs within 12 to 48 hours after abstinence. Symptoms include tactile, visual, and/or auditory hallucinations. Patients have normal sensorium and vitals.

true This patient has symptoms of alcohol hallucinosis. Alcoholic hallucinosis occurs within 12 to 24 hours of abstinence and typically resolves within 24 to 48 hours. Symptoms include tactile, visual, and/or auditory hallucinations. However, vital signs and mental orientation remain normal. The treatment is supportive therapy, which can include IV fluids and electrolyte replacement.

The diagnostic tests of choice used in determining the source of elevated ACTH production in the setting of Cushing's include a dexamethasone suppression test and corticotropin releasing hormone test. Pituitary sources will respond to both tests, whereas ectopic sources will not.

true This patient is exhibiting signs and symptoms of Cushing's syndrome, as suggested by the truncal obesity, buffalo hump, abdominal striae, and elevated ACTH levels. The next step is to determine the etiology of the elevated ACTH levels, which is done through the dexamethasone suppression test (A). Pituitary hyper secretions of ACTH will be suppressed by dexamethasone administration. However, ectopic ACTH production, is not responsive to dexamethasone suppression. Another test to be used in establishing the source of ACTH production, not mentioned in the question stem, is a corticotropin releasing hormone stimulation test. Most patients with Cushing's disease respond with ACTH and cortisol increases within 45 minutes after the intravenous administration of corticotropin-releasing hormone. Patients with adrenal tumors with increased urinary free cortisol and most with ectopic ACTH-secreting tumors do not respond because pituitary ACTH secretion is suppressed.

Bottom Line: Symptomatic abnormal uterine bleeding should be treated with administration of estrogen, followed by admission to the hospital with subsequent dilatation and curettage.

true This patient is experiencing abnormal uterine bleeding (AUB). She is experiencing menorrhagia. which is defined by heavy bleeding during menses, as opposed to metrorrhagia, which is defined as vaginal bleeding in between menstrual cycles. Menometrorrhagia is the combination of the two. For asymptomatic cases of menorrhagia, the patient could be sent home with either reassurance alone or with an oral contraceptive pill to control her bleeding. The patient, in this case, has constitutional symptoms of lightheadedness and is both tachycardic and hypotensive, which should raise some concern.The most appropriate course of action is to administer estrogen to rapidly cease the bleeding, followed by admission to the hospital and subsequent dilatation and curettage. Dysfunctional uterine bleeding (DUB) in a patient who has regular menstrual cycles (ovulatory DUB) can be treated with estrogen because these patients typically have a low estrogen state leading to heavy bleeding. DUB that is anovulatory can be treated with progesterone.

Bottom Line: Metabolic acidosis, due to tissue hypoxia, can be caused by carbon monoxide poisoning.COMBANK Insight : House fires and wood-burning stoves are 2 favorite clinical scenarios that may show up when testing carbon monoxide poisoning.

true This patient is most likely experiencing carbon monoxide poisoning. This can lead to tissue hypoxia and metabolic acidosis. Assuming there is no airway blockage, the partial pressure of oxygen is not affected by the concentration of carbon monoxide.

Although this patient is not coherently answering questions, they are currently able to maintain their airway. and stable from a respiratory standpoint with oxygen delivered per nasal cannula. If they were to decompensate, with decreasing oxygen saturations despite increasing oxygen delivery then intubation may become necessary.

very impt

Malabsorption secondary to bowel resection can lead to vitamin deficiencies, which can present in ocular, dermatologic, and even neurologic dysfunction. Bitot spots in the eyes present on the conjunctiva and are caused by ---- deficiency.

vitamin A

Chalazia are chronic lipogranulomatous inflammatory responses to the sebum that is released into the tissue surrounding a meibomian gland. Conservative therapy is most appropriate in the acute phase and typically consists of warm compresses and eyelid hygiene. Surgical excision is reserved for chronic lesions that have failed conservative therapy with warm compresses and lid hygiene.

true This patient is presenting with a chalazion. Acute-phase treatment consists of warm compresses and eyelid hygiene. This is the result of an obstructed meibomian gland in the eyelid, which is a sebaceous oil gland that produces 1 of the 3 tear film layers. The acute reaction is the result of the sebum from the gland being released into the surrounding tissue and eliciting a lipogranulomatous inflammation. In contrast, a hordeolum is an acute infection in the glands on the eyelid. There are 6 types of strains that can occur at the sphenobasilar synchondrosis (SBS): flexion/extension, torsion, sidebending/rotation, vertical strain, lateral strain, and compression. The osteopathic findings stated above describe a right torsion. A torsion is a type of strain that occurs when there is a twisting at the sphenobasilar synchondrosis. The sphenoid and other related structures of the anterior cranium rotate in one direction about an anterioposterior axis, while the occiput and the posterior cranium rotate in the opposite direction. The torsion is named for the greater wing of the sphenoid that is more superior. A torsion can be considered physiologic if it does not interfere with the flexion/extension components of the mechanism.

Bottom Line: Intra-abdominal adhesions are responsible for the majority of small bowel obstructions and should be suspected in patients presenting with abdominal distension in the presence of other characteristic signs/symptoms such as nausea, bilious vomiting, abdominal discomfort, and diarrhea (early finding).COMBANK Insight : Gastrointestinal issues are a heavily tested subject. Start by learning how to recognize the common diseases and then learn the tests used to diagnose them. After you have mastered diagnosis, focus on treatments.

true This patient presented with sudden-onset abdominal pain and bilious vomiting concerning for small bowel obstruction. Intra-abdominal adhesions are the most common cause of mechanical small bowel obstruction in the United States. Of the options listed, this would be the most likely.About 10% of small bowel obstructions occur in the presence of prior abdominal surgery. The development of abdominal adhesions is often due to foreign body reactions to exposed sutures, serosal irritation, spilled intestinal contents, and talc from personal protective equipment. For those adhesions not caused by previous surgery, malignancy also accounts for about 10% of small bowel obstructions. Other causes include abdominal wall hernias (5%-7%), internal hernias, volvulus, abscess, intussusception, radiation stricture, gallstone ileus, Meckel diverticulum, ingested foreign bodies, and mesenteric ischemia. Prompt diagnosis and treatment of small bowel obstructions are important to prevent bowel necrosis. Initial management includes nasogastric tube to suction, fluid resuscitation, and supine/upright abdominal radiographs. With medical management, 65% to 85% of small bowel obstructions will resolve without further intervention. Bottom Line: The initial approach for the evaluation of a suspected small bowel obstruction should include supine and upright plain films of the abdomen.COMBANK Insight : Gastrointestinal conditions are a heavily tested subject. Start by learning how to recognize the common diseases and then learn the tests used to diagnose them. After you have mastered diagnosis, focus on treatments.

Bottom Line: Batteries in the esophagus should be removed immediately. Batteries in the small intestine should be observed in an asymptomatic, stable patient.A useful resource for health care professionals when managing patients with battery ingestions is the National Battery Ingestion Hotline.COMBANK Insight : Treatment strategies for the ingestion of toxic substances is a highly tested topic on COMLEX and should be reviewed. There are usually one or two questions per exam pertaining to this topic. Know when patients need emergent intervention versus observation.

true This patient should be observed with consideration of repeat imaging as the patient is asymptomatic, has normal vital signs, has a normal physical exam, and the battery is located in the jejunum, not in the stomach, esophagus, or trachea. Critical history components include: the battery type, time of ingestion, number of batteries ingested, if any magnets were ingested, and any symptoms that have already occurred. Concerning symptoms include chest pain, cough, shortness of breath, abdominal pain, hematemesis or hematochezia, fever, and refusal of oral intake. Abnormal vital signs should raise concern for complications.Diagnosis is made by history and by plain radiograph. Radiographs should cover the entire GI tract from mouth to anus. Management of battery ingestion starts with addressing the airway, breathing, and circulation. Maintain NPO (nothing by mouth) status initially. If radiographs reveal evidence of esophageal impaction or if the battery is located in the stomach, emergent endoscopy is warranted. If the patient is asymptomatic, they may be observed as an outpatient and do not require emergent intervention. They should be given strict return precautions (return to the emergency department with any new abdominal pain, fever, vomiting, rectal bleeding) and may require outpatient follow-up imaging. Button batteries that are in the intestines usually pass within one week. Radiographic imaging may be obtained in follow-up to confirm passage.

Bottom Line: A strong association exists between children with type 1 diabetes and thyroid disease. All children with a new diagnosis of type 1 diabetes mellitus should be screened.

true Thyroid function testing should be performed, regardless of whether or not the patient presents with symptoms of thyroiditis. Up to 20% of children with diabetes mellitus type 1 (DM-1) have circulating antithyroid antibodies. Additional studies have also shown that, as compared to the general population, individuals with DM-1 have up to a fourfold increased risk for clinical significant autoimmune thyroid disease.

Allergic conjunctivitis tends to be bilateral and is often associated with a known environmental allergen. Suspicion should be high in patients with other allergic findings. After avoidance of the offending agent, topical antihistamines provide the greatest relief of symptoms.

true Topical antihistamine therapy is usually a first-line pharmacotherapeutic choice for the management of allergic conjunctivitis. Systemic anti-inflammatory medications are also useful. Allergic conjunctivitis should primarily be managed with avoidance of offending substances. Allergy testing may help shed light on the offending substance. Considering the stem, this patient likely has indoor allergies attributable to dust mites likely found on his pillow case or within his pillow. Viral conjunctivitis may be either unilateral or bilateral and almost universally self-resolves. Many of the same viruses that cause upper respiratory tract infections will involve the conjunctiva, and ophthalmic symptoms often resolve with upper respiratory symptoms. There is no available pharmacotherapy. Antibiotic eye drops would be useful for bacterial conjunctivitis. Suspicion of a bacterial etiology would be increased if the history included frank purulence with matting of one eye causing the eye to stick shut.

Bottom Line: Suspect CMV esophagitis in immunocompromised patients presenting with odynophagia, larger ulcers, and biopsy revealing intracytoplasmic inclusion bodies.

yes

Tricyclic antidepressants are a type of anticholinergic drug used to treat depression. Overdose on tricyclic antidepressants tends to display the classic anticholinergic toxidrome symptoms. Mydriasis, hypo-/hypertension, tachycardia, urinary retention, decreased bowel sounds, flushed/dry skin, confusion/agitation/hallucinations, and hyperthermia are common signs and symptoms (Hot as Hades, Mad as a Hatter, Blind as a Bat, Dry as a Bone, and Red as a Beet). Electrocardiogram changes tend to include QRS widening, tachycardia, and QTc prolongation, which can lead to ventricular tachycardia. First-line treatment for tricyclic antidepressant overdose is sodium bicarbonate. It works by both reversing metabolic acidosis and increasing the plasma sodium level. Charcoal administration and/or gastric lavage should also be performed as soon as possible to decrease drug absorption and to remove the drug from the stomach, respectively. Other treatments include lorazepam for seizures, lidocaine for arrhythmias, magnesium for torsade de pointes, and norepinephrine for hypotension.

true Tricyclic antidepressant toxicity causes blockade of fast sodium channels, leading to slowing of phase 0 depolarization and QRS prolongation. First-line treatment consists of sodium bicarbonate administration. Tricyclic antidepressant toxicity does cause inhibition of potassium channels, which leads to QTc prolongation and may lead to torsades de pointes.

Bottom Line: Pelvic floor strengthening is the best long-term treatment for patients suffering from uterine prolapse. Topical estrogen is an important adjunct in the conservative management of patients with uterine prolapse.

true Uterine prolapse occurs due to the weakening of the pelvic floor musculature, leading to herniation of the uterus into the vagina. In addition to connective tissue, the pelvic floor is composed of muscle fibers of the levator ani and coccygeus. The most cost-effective long-term therapy involves strengthening the pelvic floor by performing Kegel exercises.

Bottom Line: Vasovagal is the most common type of syncope usually occurring in healthy individuals.COMBANK Insight : Be sure to be able to distinguish between the types of syncope as they may present in a similar matching question set.

true Vasovagal is the most common type of syncope. It usually occurs in otherwise healthy people. Excess vagal tone causes a rapid decrease in blood pressure. Episodes are triggered by physical or emotional stress. Sweating, palpitations, yawning, and nausea commonly occur before the episode. Rapid recovery follows.

Bottom Line: To prevent wrong-site surgeries, it is best to confirm and place initials on the operative extremity with the patient in the pre-operative area and perform a "time-out" with all personnel prior to beginning the procedure in the operating room suite.

true Wrong-site surgery is an avoidable and indefensible error by a surgeon. It affects all surgical specialties and is a result of a break-down in both surgeon and system protocols. Wrong-site surgery is completely preventable by having the surgeon, with the consultation of the patient, place his or her initials on the correct operative site using a surgical marker with the initials of the patient as well. The initials should be visible after the patient is draped and prepped in the operating room and a "time-out" protocol should be initiated prior to beginning the surgical procedure. This "time-out" is used to confirm the type of procedure, correct surgical site, and side with all individuals in the operating room.

This patient is presenting with third trimester painless bleeding without contractions or fetal distress. The most likely diagnosis is placenta previa which occurs due to abnormal implantation of the placenta close to the cervical os. Of the choices listed, a prior C-section is the most likely risk factor for this condition. Other risk factors include multiparity and uterine surgery.

true prior c-section, multiparity and uterine surgery Bottom Line: Always do an ultrasound before doing a pelvic exam in third-trimester bleeding to rule out placenta previa. Placenta previa is a contraindication for a pelvic exam. The first diagnostic step for any woman presenting with third-trimester bleeding is an ultrasound. An ultrasound is highly sensitive for placenta previa and thus can rule it out. It can show where the placenta lies in relation to the cervical os. There are different types of placenta previa, and these types are based on where the placenta is located in relation to the os. Placenta previa may be low-lying, marginal, or complete.

truee

Bottom Line: The basic laboratory workup for dementia includes TSH, CBC, CMP, B12, and folate, and can include RPR or HIV testing as well.

truee The most important tests in this patient include the TSH given his complaints of constipation and fatigue (rule out hypothyroidism) as well as a CBC to evaluate for anemia (due to fatigue).The general medical workup for dementia includes the following blood tests: TSH to rule out significant underlying hypothyroidism which may be contributing to cognitive impairment B12 and folate to rule out underlying vitamin deficiencies which may be contributing to cognitive impairment Comprehensive metabolic profile and CBC are routine screening to rule out electrolyte disturbances, anemia, or liver failure contributing to changes in memory and neurological functioning. These are not generally dementia specific but may find other underlying disorders which may be contributing. RPR or HIV depending on history for evaluation of underlying AIDS dementia or tertiary syphilis

Daytime drowsiness and slurred speech are characteristic of African sleeping sickness, caused by Trypanosoma brucei rhodesiense and gambiense. Their vector is the bloodsucking ----

tsetse fly.

The ---- is responsible for the cutaneous innervation of the dorsal aspect of the little finger. Because of the anatomic positioning of the ulnar nerve, it is subject to entrapment and injury by a wide variety of causes. It is the second most common entrapment neuropathy in the upper extremity. One of the most severe consequences is loss of intrinsic muscle function in the hand. Presenting symptoms of ulnar nerve entrapment can vary from mild transient paraesthesias in the ring and small fingers to clawing of these digits and severe intrinsic muscle atrophy.

ulnar nerve

The ------ innervates several muscles of the hand, including the palmaris brevis, dorsal interosseous muscles, palmar interosseous muscles, adductor pollicis, and the third and fourth lumbricals.

ulnar nerve

Bottom Line: Suspect Fitz-Hugh-Curtis syndrome in a young, sexually active female with symptoms of pelvic inflammatory disease (PID) and right upper quadrant pain.COMBANK Insight : Fitz-Hugh-Curtis syndrome has been tested several times in the past few years. The above scenario is a great example of how you can use the age of the patient, along with information given in the case, to make the correct diagnosis. Be careful not to overthink these questions.

yes Fitz-Hugh-Curtis (FHC) syndrome is an extrapelvic manifestation of acute and chronic pelvic inflammatory disease (PID) and has been shown to occur in 4-10% of cases. FHC occurs in the setting of PID in which there is development of perihepatitis or inflammation of the liver capsule and adjacent peritoneum rather than a hepatitis which refers to inflammation of the liver stroma itself. The characteristic symptoms of FHC include right upper quadrant pain often with pleuritic chest pain or flank pain due to diaphragmatic irritation. On occasion this can be referred to the right shoulder, as in this patient. Sometimes, the right upper quadrant pain is the presenting symptom and can mask the underlying diagnosis of acute PID. In the setting of perihepatitis, the liver stroma is usually unaffected and aminotransferases remain relatively normal with mild variation depending on inflammation. FHC can be diagnosed on laparoscopy by visualization of purulent or fibrinous exudate between the liver capsule and abdominal wall ("violin string" adhesions). There are three theories regarding the development of this condition: that there is ascending infection through which microbes travel into the peritoneum through the fallopian tubes, lymphatic spread, or hematogenous spread. It is not clear which of these is to blame for which presentation of this disease.

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