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* For ppl. don't have these MCQ's...........
 #273954  
  aiissman - 02/25/08 17:24
 
  brainX Digital Learning System
Study Session of KnowledgeBase: Practice Exam 4

Record # 1

Question/Fact:

A 42-year-old man comes to your office complaining of feeling full after eating only salad at dinner for the past three months. He has felt fatigued recently while gardening and going to the shopping mall. Physical examination reveals a mild pallor, clear lungs, no murmurs, and no cervical or axillary adenopathy. There is massive splenomegaly, and the liver edge is felt one inch below the right costal margin. There are no ecchymoses or petechiae. Laboratory studies show: WBC 140,000/mm3, with 82% neutrophils, 10% basophils, and no blasts; hemoglobin 10 mg/dL, hematocrit 30%, platelets 320,000/mm3. The peripheral smear shows a left-shifted myeloid series and bands. What treatment would you recommend first?

(A) Leukapheresis
(B) Hydroxyurea
(C) Imitanib (Gleevec) STI 571
(D) Autologous bone-marrow transplant
(E) Interferon-alpha

Answer:

(C) Imitanib (Gleevec) STI 571

Explanation:

The best initial therapy for chronic myelogenous leukemia is the oral tyrosine kinase inhibitor, imitanib. Although this drug does not cure the disease, it offers an excellent hematologic response and often eliminates the Philadelphia chromosome. The only reliably curative treatment for CML is allogeneic bone-marrow transplantation, not an autologous transplantation. The crucial factor in the success of a transplant is the availability of HLA-matched siblings for donation. The cure rate is 70 to 80% if done within one year of diagnosis (if HLA-matched) but only 40 to 60% if an HLA match is found through a registry of nonfamilial donors.

The success of a drug used for CML is assessed by determining who becomes Philadelphia chromosome negative. If there is a complete cytogenetic response, survival rates are 90%. Hydroxyurea was formerly the treatment for CML patients awaiting transplantation. Hydroxyurea does not convert anyone to the Philadelphia chromosome-negative state and is only used to lower the cell count. Interferon-alpha was used to prolong the chronic phase of CML and after prolonged therapy could remove the Philadelphia chromosome in a minority of patients (<20-30%). Interferon has significant side effects, however, such as fatigue, myalgias, and anorexia, and it requires motivated patients. Imitanib or Gleevec (STI571) is a new oral drug that inhibits the tyrosine kinase activity of the bcr-abl gene and has shown excellent efficacy. There is a hematologic response in 80 to 90% of patients, and as many as three-quarters of these become Philadelphia chromosome negative. Although it is infinitely less dangerous than an allogeneic transplant, imitanib does not offer the same chance at a permanent cure.

Leukapheresis is performed if the patient shows signs of leukostasis or the sludging of the white cells in the vasculature, causing confusion, blurry vision, dyspnea, and stroke. This patient has a very high cell count but does not have any of these symptoms.

Record # 2

Question/Fact:

A 26-year-old athletic woman comes to the office for a routine visit. She jogs 2 to 5 miles per day and does not drink or smoke. Her only complaint is some occasional "bone pain" in her right lower leg when she runs. Her physical examination is unremarkable. Routine laboratory studies show: potassium 4.5 mEq/L; creatinine 0.8 mg/dL; and hematocrit 42%. Urinalysis shows a yellow color; pH 5.0; no white cells, red cells, or casts; and there is 1+ protein. Your initial management of this patient would be:

(A) Renal ultrasound
(B) 24-hour urine collection
(C) Split urine test
(D) Repeat urinalysis in 4 to 6 weeks
(E) Renal biopsy

Answer:

(D) Repeat urinalysis in 4 to 6 weeks

Explanation:

This patient has asymptomatic, non-nephrotic range proteinuria. There are four types of benign, isolated proteinuria:

1) Idiopathic transient proteinuria is usually observed in young adults and refers to a dipstick-positive proteinuria in an otherwise healthy individual that disappears spontaneously by the next clinic visit.
2) Functional proteinuria refers to a transient proteinuria during fever, exposure to cold, congestive heart failure, or obstructive sleep apnea. This phenomenon is presumed to be mediated through changes in the glomerular ultrafiltration pressure and/or membrane permeability.
3) Intermittent proteinuria patients have proteinuria in approximately half of their urine samples in the absence of other renal or systemic abnormalities.
4) Postural proteinuria is a proteinuria evident only in the upright position. This disorder affects 2 to 5 percent of adolescents and may be transient (80%) or fixed (20%). Fixed postural proteinuria resolves within 10 to 20 years in most cases.

All forms of benign, isolated proteinuria carry an excellent prognosis. Isolated proteinuria detected on multiple ambulatory visits (persistent isolated proteinuria) in both the recumbent and upright position usually signals a structural renal lesion. Virtually all glomerulopathies that induce nephrotic syndrome can cause isolated proteinuria. The most common lesion on renal biopsy is mild mesangial, proliferative glomerulonephritis with or without focal segmental glomerulosclerosis. Although this entity carries a worse prognosis than benign isolated proteinuria, the prognosis is relatively good, with only 20 to 40% of patients developing renal insufficiency after 20 years. Progression to renal failure is extremely rare.

Record # 3

Question/Fact:

A 37-year-old health care worker had a PPD skin test reactive at 17 mm ten years ago at the end of her internship. She never took the recommended isoniazid. What is appropriate for this patient?

(A) Do nothing
(B) Start isoniazid for the next nine months
(C) Perform a single PPD now
(D) Yearly chest x-rays
(E) Two-stage PPD testing

Answer:

(A) Do nothing

Explanation:

If the patient had not developed tuberculosis because of the previous exposure, she is not going to now. A positive skin test confers a 10% lifetime risk of developing tuberculosis. Almost all of this is within the first two years of developing a positive reaction. There is no point in giving a patient isoniazid now to prevent tuberculosis that would have happened years ago after the initial exposure. Once a tuberculosis skin test is positive, there is no point in ever repeating the test. It will always be positive. There is no benefit to yearly chest x-rays in anyone. Two-stage PPD testing is performed in those who have either never been tested before or who had negative skin tests in the past and it has been longer than a year since the last positive test. The two-stage test is to confirm that the first test is truly negative.

Record # 4

Question/Fact:

A 52-year-old Hispanic woman presents for an employment physical examination. The patient is a recent immigrant, and she hasn't seen a doctor for fifteen years. She denies chest pain or shortness of breath. She has good exercise tolerance and doesn't have a history of cardiac problems. The blood pressure is 165/70 mm Hg, and heart rate is 72/min. No jugulovenous distention is seen, and carotid bruits are absent. On heart examination, there is a normal S1, a physiologically split S2, a II/VI systolic ejection murmur at the base, and a III/VI diastolic decrescendo murmur at the left sternal border. This diastolic murmur is best heard when the patient holds her breath while sitting or leaning forward. Which of the following is most likely to benefit this patient?

(A) Digoxin
(B) Metoprolol
(C) Nifedipine
(D) Balloon manipulation
(E) Valve replacement

Answer:

(C) Nifedipine

Explanation:

This patient has aortic valve insufficiency (AI). She has a decrescendo diastolic murmur and a wide pulse pressure. The most likely cause of aortic insufficiency in this case is a congenital bicuspid aortic valve. The coexistence of aortic stenosis and AI is almost always from rheumatic fever or congenital disease. The first step is an echocardiogram to confirm the diagnosis, establish the cause of valve disease, and evaluate the ventricular size and systolic function. Some patients with chronic aortic regurgitation have irreversible left ventricular (LV) systolic dysfunction before the onset of symptoms.

If an echocardiogram reveals LV dilatation in patients with aortic valve insufficiency, afterload reduction therapy should be started with ACE inhibitors or nifedipine. Nifedipine can help delay the progression of the disease and delay the need for surgical valve replacement. Beta-blockers have not been found to be useful in AI. They may increase the severity of regurgitation by prolonging diastole. Valve replacement is not definitely necessary because she is not symptomatic. Valve replacement can be useful in asymptomatic patients if the patient has progressive LV dysfunction with an ejection fraction of <55%. Digoxin is of extremely limited value in aortic regurgitation.

Record # 5

Question/Fact:

A 60-year-old woman comes to your office with complaints of progressive fatigue. She is unable to make it through the day without tiring and hasn't been sleeping well due to waking up in the middle of the night short of breath. She is also concerned about a 10-pound weight gain over the past month. She has a past medical history of hypertension, hypercholesterolemia, and diabetes mellitus. Her medications include metformin, atenolol, hydrochlorothiazide, and atorvastatin. The doses haven't changed over the past two years. Vital signs are: blood pressure 167/96 mm Hg, heart rate 78/min, and respiratory rate 20/min. There is some mild jugular venous distension at 30 degrees, bibasilar rales, a holosystolic murmur at the apex radiating to the axilla, and a mild pitting edema of the ankles. Which of the following would be appropriate at this time?

(A) Echocardiogram to determine direction of action
(B) Digoxin
(C) Increase the dose of atenolol
(D) Start ACE inhibitors
(E) Stop the atenolol

Answer:

(A) Echocardiogram to determine direction of action

Explanation:

At this point, there is not enough information to determine if this is systolic or diastolic cardiac dysfunction. Longstanding hypertension can lead to either type of cardiomyopathy. If an S3 gallop was heard or an echocardiogram confirmed a low ejection fraction, then choice D, ACE inhibitors, would be correct. If an S4 was heard or an echocardiogram definitely showed diastolic dysfunction, then choice C, increasing the beta-blockers, would be the correct choice for treating diastolic dysfunction. Choice B, adding digoxin, would not be appropriate at this time. Digoxin is only helpful to decrease symptoms in systolic dysfunction. If the patient still has symptoms of dyspnea after starting an ACE inhibitor, then adding digoxin to relieve symptoms would be appropriate. Beta-blockers are appropriate for both systolic and diastolic dysfunction, so choice E, stopping the atenolol, is not appropriate. The best data for evidence for a decrease in mortality are for carvedilol and metoprolol, although it is probably an effect of the entire class of medications. Switching the diuretic to a loop diuretic, such as furosemide, and starting a salt-restricted diet are generally appropriate for all forms of congestive failure.

Record # 6

Question/Fact:

What is the appropriate mode of colorectal cancer screening for the following case?

A 41 year-old man with no family history of colon cancer and complains of 10 years of increasing constipation; his diet contains poor amounts of soluble fiber.

(A) Colonoscopy now and every 10 years
(B) Flexible sigmoidoscopy now and every 5 years
(C) Colonoscopy at age 50 and every 10 years
(D) Colonoscopy now and every 10 years
(E) Stool occult cards every year; colonoscopy if positive
(F) Colonoscopy at age 40 and every 5 years
(G) Colonoscopy in 3 years
(H) Colonoscopy in 1 year
(I) Colonoscopy every 1 to 2 years

Answer:

(C) Colonoscopy at age 50 and every 10 years

Explanation:

Colonoscopy is the preferred method of screening for colon cancer. Average-risk persons should undergo colonoscopy at age 50, and if normal, every 10 years. If a polyp is found, the colonoscopy should be repeated after 3 years. When there is a family history of colon cancer, screening should begin at age 40 or ten years prior to the age of the family member. The earlier date is respected. Follow-up examinations for persons with family histories of colon cancer should occur at 5-year intervals. When there are multiple family members, screening colonoscopy should be performed at age 25 and every 1 to 2 years (characteristic of persons with hereditary nonpolyposis colorectal cancer (Lynch syndrome). Colonoscopy is recommended 1 year after a hemicolectomy for colon cancer to verify the absence of recurrence and the presence of new lesions.

Record # 7

Question/Fact:

An elderly woman in a nursing home is being evaluated for her hypothyroidism. You find her thyroid-stimulating hormone (TSH) level to be elevated at 13 mU/L (normal 0.4-5 mU/L). She has been on the same dose of levothyroxine for six months since the time of diagnosis. Her past medical history is significant for anemia, peptic ulcer disease, and a stroke with right hemiparesis. She also has hypertension and chronic renal failure. The staff reports to you that she has had no change in her mental status, skin, or bowel movements. Since your last visit two months ago, an iron supplement was added to her regimen of amlodipine, famotidine, levothyroxine 75 μg, vitamin C, and aspirin. Her hematocrit is 40%, and rest of her physical examination is unremarkable. What is the next appropriate step in her management?

(A) Radioactive-iodine uptake level
(B) No change in management
(C) Titers against thyroperoxidase and thyroglobulin
(D) MRI of the brain
(E) Stop the iron and aspirin
(F) Stop the famotidine

Answer:

(E) Stop the iron and aspirin

Explanation:

This patient most likely has poor control of her hypothyroidism due to decreased absorption of her thyroid-hormone replacement because of an interaction with iron sulfate and vitamin C. Because her hematocrit is normal she doesn't need the iron anyway, and the vitamin C is most likely just being given to increase the absorption of the iron. Calcium supplementation and Carafate can also interfere with the absorption of thyroid hormone.

Record # 8

Question/Fact:

A 32-year-old woman with no significant past medical history comes to your office complaining of a severe headache. She describes a severe unilateral, nonpulsating, periorbital pain for about two hours. The patient has noticed that her right eye is red. She does not associate the headaches with any specific activity, food, or stressors. She denies fever or chills and has used ibuprofen and acetaminophen without relief. She is afebrile and has a blood pressure of 144/76 mm Hg. Physical examination reveals a morbidly obese female with a nontender face, temporal arteries, and sinuses. There is no neck stiffness. Her right eye is injected. The pupils are equal and round, but the right eye is nonreactive. The patient complains of blurred vision. Visual acuity testing shows 20/40 on the right and 20/20 on the left. Funduscopic and neurological examinations are normal. What would be the next step in the management of this patient?

(A) Oxygen inhalation therapy
(B) Acetazolamide
(C) Head CT scan
(D) Prednisone for 10 days, followed by rapid taper
(E) Pilocarpine

Answer:

(B) Acetazolamide

Explanation:

Because of this patient's history of headache, blurry vision, and a nonreactive pupil, this patient has acute-angle closure glaucoma. When the pupil becomes mid-dilated, the peripheral iris blocks aqueous outflow via the anterior chamber angle, and the intra-ocular pressure rises abruptly, producing pain, injection, corneal edema, and blurred vision. It is best treated acutely with acetazolamide to lower intraocular pressure. Topical beta-blockers can be used on a long-term basis to prevent an increase in intraocular pressure. Pilocarpine can be used to induce miosis and lower intraocular pressure as well, but it should be started after the acetazolamide. The symptoms of acute-angle closure glaucoma are similar to cluster headaches. These include a unilateral, nonthrobbing headache and the association with parasympathetic over activity, such as lacrimation, rhinorrhea, and injected conjunctiva. Cluster headaches last 30 minutes to two hours, are seen more often in men than woman, and often occur at the onset of sleep. Patients are usually hyperactive during the headache. Given the history of sudden headaches with no prior episodes and the nonreactive pupil, this patient is not likely to have cluster-type headaches. Oxygen inhalation and prednisone can be used to acutely treat cluster headaches.

Record # 9

Question/Fact:

A 60-year-old man presents with recurrent episodes of dyspnea on minimal exertion. He has a prior medical history significant for hypertrophic cardiomyopathy for 15 years, and for the past year his symptoms have become more severe and bothersome. He frequently complains of chest pain, orthopnea, nocturnal dyspnea, chronic nonproductive cough, weight gain, and peripheral edema. His medications include atenolol 50 mg BID, verapamil, disopyramide, and Lasix. Physical examination reveals an anxious tachypneic male who is afebrile with a blood pressure of 110/70 mm Hg without pulsus paradoxus. The respiratory rate is 30/min. Jugular veins are distended, and the heart sounds are distant. There are third and fourth heart sounds present, as well as bilateral rhonchi. The liver is enlarged, and pedal edema is present. The EKG shows nonspecific ST-T changes in the lateral leads. Chest x-ray reveals cardiomegaly with pulmonary congestion. The echocardiogram displays ventricular dilatation and mitral regurgitation with an ejection fraction of 35%. Three sets of cardiac enzymes are negative. What is the best medical management at this time?

(A) Add captopril to present regimen
(B) Increase the dose of Lasix and continue present regimen
(C) Stop the verapamil and disopyramide and start captopril
(D) Increase the dose of beta-blocker, verapamil, and Lasix; stop the disopyramide and start captopril
(E) Continue with present management

Answer:

(C) Stop the verapamil and disopyramide and start captopril

Explanation:

In 5% of patients, hypertrophic cardiomyopathy may "burn out" into a condition more typical of dilated cardiomyopathy. This is characterized by the development of thinner myocardial walls, diminishment of the outflow gradient, and the development of mitral regurgitation. These patients tend to have symptoms of congestive heart failure (CHF) at left ventricular ejection fractions that are not severely reduced, often in the range of 30 to 40%, as opposed to the usual case of dilated cardiomyopathy in which severe symptoms are rare above an ejection fraction of 25%. When this occurs, such patients should discontinue verapamil and disopyramide, which work to decrease inotropic state, and continue beta-blockers only at low doses and with caution. Patients should begin therapy with ACE inhibitors and diuretics as needed for fluid retention, as one would in any other patient with dilated cardiomyopathy.

Record # 10

Question/Fact:

A 28-year-old woman presents to her primary care clinic with complaints of fatigue and loss of appetite for the last three weeks. She has difficulty walking because of pain in her right knee and lower back. About two months ago, after coming back from a trip to Mexico, she was treated for diarrhea and symptoms of dysuria. Her past medical history is unremarkable. Her father has had severe chronic back pain since he was 30 years old. On physical examination, pertinent findings include moderate conjunctival hyperemia. Her range of motion is moderately decreased in the right knee joint and lumbar spine. There is some tenderness on palpation of the spine at the level of T12 to L5 bilaterally, as well as on palpation of the right knee. There is no visible joint swelling or deformity. During the examination, she mentions a somewhat increased vaginal discharge over the past two months. The discharge looks mucoid, but you don't see anything unusual on speculum examination. The smear from the cervix shows more than 10 neutrophils/hpf. While waiting for culture and other test results, what would be the most appropriate treatment for this patient?

(A) Indomethacin
(B) Methylprednisolone
(C) Sulfasalazine
(D) Physical therapy
(E) Doxycycline and ceftriaxone

Answer:

(E) Doxycycline and ceftriaxone

Explanation:

This patient presents with Reiter's syndrome as a manifestation of "reactive arthritis." Reactive arthritis is an acute, nonsuppurative, sterile inflammatory arthropathy, occurring after an infectious process but at a remote site. The microbial pathogens commonly associated with reactive arthritis are Shigella, Salmonella, Yersinia, Campylobacter, and Chlamydia. Reactive arthritis begins as an asymmetrical oligoarthritis, often preceded by an infectious event by 1 to 4 weeks. C. trachomatis is thought to be responsible for up to 10% of cases of early inflammatory arthritis. It develops in 1 to 3% of patients with chlamydial urethritis. The diagnosis is suggested by the detection of the involvement of at least one joint, symptoms of genitourinary infection, and the detection of Chlamydia on a genitourinary swabs or urine ligase chain reaction. Women may not have any urogenital manifestations at all. Only one third will have lower back pain, enthesitis, or radiographic sacroiliitis. In those with reactive arthritis secondary to chlamydia, the suggested treatment is a course of doxycycline.

NSAIDs, such as indomethacin or Naprosyn, are used in ankylosing spondylitis and Reiter's syndrome. NSAIDs alone can give some symptomatic improvement but won't treat the underlying cause. Systemic corticosteroids are reserved for severe disease flares. Slow-acting, antirheumatic drugs, such as sulfasalazine or methotrexate, should be considered when chronic peripheral arthritis, enthesitis, or spondylitis exists and is unresponsive to NSAIDs.

Record # 11

Question/Fact:

A 22-year-old man who is a recent immigrant from Pakistan comes to the emergency department because of a shock-like sensation in his left thigh on forward flexion. His left leg becomes fatigued easily. He has a fever and has been losing weight. He was treated for tuberculosis for a long time in his country but was noncompliant with the medications. Neurological examination demonstrates lower extremity paraparesis. An MRI of the spine reveals collapsed vertebrae at the level of T11 to L1. Which of the following is the most appropriate next step in his management?

(A) Start nafcillin
(B) Lumbar puncture
(C) Orthopedic consultation
(D) Bone scan
(E) Immediate radiotherapy

Answer:

(C) Orthopedic consultation

Explanation:

The clinical presentation and MRI findings are consistent with tuberculosis of the spine, or Pott's disease. The onset of symptoms is generally insidious and is often not even accompanied by fever. Tuberculosis usually involves the midthoracic spine. Anterior erosion of vertebral bodies causes collapse, resulting in kyphosis. Lumbar puncture is not needed, and in this case, it would be difficult due to distortion of the architecture of the vertebral body. Paraplegia is the most serious complication. In the presence of new paraparesis, immediate orthopedic consultation should be called for bone biopsy and possible fixation of the vertebrae. Bone scan will delay treatment, such as decompression of spinal cord, and adds little to the diagnosis because it will not substitute for a bone biopsy. Cultures of the bone can be done at the time of surgery. There is no evidence that this man has a malignant process, and immediate radiotherapy will not be appropriate at this time. The management of tuberculosis of the spine is with the same initial four-drug regimen used in pulmonary tuberculosis. The only major difference is that the duration of therapy should be extended to 12 months or longer.

Record # 12

Question/Fact:

A 65-year-old woman is admitted to the hospital on Friday night with an episode of squeezing, substernal chest pain that occurred while the patient was watching her favorite TV show. The pain lasted for twenty minutes and was not relieved by nitroglycerin. A dobutamine stress echocardiogram was done a month ago by her private physician, which showed posterior and lateral wall motion abnormalities. Her past medical history is significant for diabetes mellitus.

On arrival at the hospital, an EKG shows ST-segment depression in the lateral leads. She is started on aspirin, nitrates, beta-blockers, and intravenous unfractionated heparin. Three sets of cardiac enzymes are negative. A complete blood count shows a white cell count of 7,800/mm3, a hematocrit of 37%, and a platelet count of 180,000/mm3. The medications are continued, and she is transferred from the cardiac care unit on Sunday evening with plans for a coronary angiography the next day.

On Monday, the patient complains of pain in the right leg. The physical examination is unremarkable, except for moderate right-calf tenderness. The venous Duplex shows thrombosis of the right popliteal vein. Another complete blood count shows: WBC 9,900/mm3, hematocrit 38.8%; and platelets 45,000/mm3. The prothrombin time (PT) is 13.6 seconds, INR 1.0, and partial thromboplastin time (PTT) 68 seconds.

What is your next step in the management of this patient?

(A) Continue unfractionated heparin and start coumadin after the angiogram
(B) Switch unfractionated heparin to low-molecular-weight heparin
(C) Immediately stop heparin and remove heparin-coated catheters
(D) Corticosteroids
(E) Switch unfractionated heparin to lepirudin

Answer:

(E) Switch unfractionated heparin to lepirudin

Explanation:

This patient is suffering from heparin-induced thrombocytopenia (HIT) and also a deep venous thrombosis, which is most likely the result of this disorder. One to 3% of patients who receive unfractionated heparin will develop antibodies against platelets. All forms of heparin must be stopped when HIT occurs. You cannot just switch to low-molecular-weight heparin. Although low-molecular-weight heparin carries a much smaller risk of developing thrombocytopenia, 70% of the antibodies that develop will cross-react with low-molecular-weight heparin. Again, all heparins must be stopped because 30% of those with HIT will develop some form of thrombosis. Seventy-five percent of the time, the thrombi are venous, and only 25% are arterial. This patient has a thrombosis and therefore needs an alternate type of anticoagulation. Coumadin will not be effective rapidly enough, and the patient is also scheduled for angiography the following day.

Lepirudin is an analog of hirudin. These drugs are natural anticoagulants that inhibit thrombin and are derived from leeches. They do not cross-react with HIT-induced antibodies. Lepirudin can be monitored with the PTT. Danaparoid is a heparinoid that is no longer marketed in the United States.

Record # 13

Question/Fact:

A 35-year-old woman (gravida 1, para 0) presents to the emergency room at 32 weeks of pregnancy with complaints of progressive shortness of breath over the last week and paroxysmal nocturnal dyspnea for the last 3 weeks. The patient states that she recently started to use three pillows during sleep. The patient has a history of atrial fibrillation and uses digoxin for rate control. She got married two years ago and has been unable to conceive for more than one year. Her pulse is 120/min and irregular, and her blood pressure is 130/85 mm Hg. Physical examination reveals jugular venous distension, bibasilar lung crackles, a loud S1, an opening snap following S2, and a low-pitched diastolic murmur best heard in the left lateral decubitus position.

In the emergency department, the patient receives oxygen via nasal canula, furosemide 80 mg intravenously, and diltiazem 20 mg intravenously with no significant improvement in her symptoms. Echocardiography shows normal left ventricular systolic function with a mitral valve area of 0.9 cm2.

Which of the following is the most effective therapy in her management?

(A) Initiate therapy with lisinopril
(B) Start metoprolol
(C) Balloon valvuloplasty
(D) Cesarean section
(E) Increase the dose of digoxin

Answer:

(C) Balloon valvuloplasty

Explanation:

Almost all cases of mitral stenosis in adults are secondary to rheumatic heart disease. Most cases of mitral stenosis occur in women. Mitral valve stenosis impedes left ventricular filling, thereby increasing left atrial pressure as a pressure gradient develops across the mitral valve. Elevated left atrial pressure is referred to the lungs, where it produces pulmonary congestion. In mitral stenosis, the symptoms of left ventricular failure (dyspnea on exertion, orthopnea, and paroxysmal nocturnal dyspnea) are usually not due to left ventricular dysfunction, but rather to the mitral stenosis itself preventing the flow of blood out of the lungs.

The physiologic changes imposed by pregnancy can cause cardiac decompensation in any patient with a significant cardiac abnormality, especially in patients with mitral and aortic stenosis. This is because of the 50% rise in plasma volume routinely occurring during pregnancy. Symptoms of mitral stenosis become more severe during pregnancy because of the increase in diastolic flow and the rate-related shortening of the duration of diastole. Left atrial pressure rises, and dyspnea or pulmonary edema can occur in previously asymptomatic individuals. Atrial fibrillation also often leads to acute decompensation because of a shortened diastolic filling time as well.

Despite the appropriate use of diuretics to relieve pulmonary edema and the use of intravenous diltiazem to slow down the ventricular rate, in this case with atrial fibrillation, both the mother and the fetus are at high risk of injury because of pulmonary edema and hypoxemia. Balloon valvuloplasty is the most direct and effective form of therapy in this critical situation. Ending the pregnancy at 32 weeks' gestation is more hazardous to the fetus than the radiation exposure during the procedure. ACE inhibitors will not help, and besides that, they are contraindicated in pregnancy because of their teratogenic effects.

Record # 14

Question/Fact:

A 57-year-old man comes to the office with three days of cough and sputum production. Physical examination reveals rales at the left base. The chest x-ray shows a left lower lobe infiltrate. His respiratory rate is 22/min, and his oral temperature is 102 F. The pulse oximeter shows a 94% saturation on room air. How would you manage this patient?

(A) Wait for results of Gram stain and sputum culture
(B) Oral amoxicillin
(C) Oral gatifloxacin
(D) Intravenous cefuroxime
(E) Oral amoxicillin/clavulanic acid

Answer:

(C) Oral gatifloxacin

Explanation:

This patient can be safely treated as an outpatient. His respiratory rate, although raised at 22/min, is still <30/min. He is only mildly hypoxic. He is relatively young and has no other comorbid conditions, such as renal, liver, lung, or heart disease or cancer. Fever alone is not a reason to hospitalize someone. Sputum Gram stain and culture have a <50% sensitivity in the detection of a specific organism. Even if they were 100% sensitive, there would still be no reason to defer therapy until the results were obtained. Oral amoxicillin will not cover Legionella, Chlamydia, and Mycoplasma. It is also not as effective against pneumococcus as the newer fluoroquinolones, even when combined with clavulanic acid. Standard therapy for the outpatient management of community-acquired pneumonia is either with a macrolide or a new fluoroquinolone, such as levofloxacin, moxifloxacin, or gatifloxacin.

Record # 15

Question/Fact:

A 56-year-old man comes to the office for evaluation of his diabetes. He is well maintained on a sulfonylurea and metformin. He is a nonsmoker and has no history of hypertension or coronary disease. His father is the Jedi master Yoda who lived to be 900 years old without coronary disease. His glucose level today in the office is 135 mg/dL (normal 60-110 mg/dL), hemoglobin A1C 7.2% (normal 4-7%), and his LDL is 145 mg/dL. What is the most appropriate management of this patient?

(A) No further therapy indicated
(B) Step 2 diet, restricting lipid intake alone
(C) Niacin
(D) Statins

Answer:

(D) Statins

Explanation:

The presence of diabetes is considered the equivalent of coronary disease in the management of hyperlipidemia. Diabetes is such a strong risk for coronary disease and myocardial infarction that drug therapy should be started if the LDL is >130 mg/dL, with the goal of driving it under 100 mg/dL. It is optional even to start lipid-lowering drug therapy even with an LDL between 100-130 mg/dL. Niacin is not ideal in the management of those with diabetes because it impairs the ability to control glucose levels. Beside its effects on glucose levels, the best evidence for an improvement in mortality is with the use of the statins.



Record # 16

Question/Fact:

A 69-year-old man with a prolonged history of hypertension and diabetes mellitus is brought to the emergency department by his daughter with right lower extremity weakness and slurred speech. These symptoms developed suddenly over the last two hours. One month ago, he underwent laparoscopic cholecystectomy. He had a severe hematuria six weeks ago. Upon arrival, his blood pressure is 160/90 mm Hg, and his heart rate is 72/min. Neurological examination reveals right lower extremity weakness with 3/5 motor strength and decreased sensation in the same leg. Neck examination reveals a mild carotid bruit on the left. The EKG shows normal sinus rhythm. A CT scan of the head is normal. All laboratory tests are normal. Which of the following is most appropriate at this time?

(A) Aspirin 325 mg daily
(B) Aspirin 325 daily and dipyridamole 200 mg twice a day
(C) Coumadin
(D) tPA intravenously
(E) Heparin intravenously

Answer:

(D) tPA intravenously

Explanation:

This patient is evaluated within three hours after the onset of his neurological deficit, and he should receive tPA. It is the only approved medication for the treatment of acute ischemic stroke. It is effective in reducing neurological deficits in selected patients without CT-scan evidence of intracranial hemorrhage when administered within three hours of the onset of symptoms. Administration of tPA after three hours has not been proven to be effective or safe. A laparoscopic cholecystectomy a month ago and hematuria alone are not contraindications to the use of tPA. They are relatively minor risks for an increased risk of bleeding. Although the blood pressure is elevated in this case, it is still <185/110 mm Hg. Contraindications to the use of thrombolytics are a recent hemorrhage, an increased risk of hemorrhage, a recent myocardial infarction, an arterial puncture at a noncompressible site within the preceding seven days, major surgery within fourteen days, a systolic blood pressure above 185 mm Hg, or a diastolic pressure above 110 mm Hg. Gastrointestinal or severe urinary tract hemorrhage is also a contraindication to thrombolytic therapy. Heparin has no role in the management of patients with completed stroke, except when there is a cardiac source of embolization, such as a thrombus or atrial fibrillation. Treatment is then started with heparin and warfarin. There is an increased risk of early and serious intracranial and extracranial bleeding, and no long-term neurological benefit with heparin treatment for patients with acute ischemic stroke.

Record # 17

Question/Fact:

In determining fulminant hepatic failure, which of the following parameters should be closely monitored because it is best for predicting progression to failure?

(A) AST and ALT
(B) Alkaline phosphate
(C) Bilirubin
(D) Prothrombin time
(E) White blood cell count

Answer:

(D) Prothrombin time

Explanation:

In patients with severe hepatitis, the synthetic function of the liver most accurately predicts the mortality. The prothrombin time is based on the hepatic synthesis of factors 2, 5, 7, 9, 10, and fibrinogen. Thus, choice D is the correct answer.

Record # 18

Question/Fact:

A 35-year-old woman presents to your office complaining of a cough. She has a history of hyperthyroidism, which has been well controlled with propylthiouracil for the past 6 months. The cough has been getting progressively worse over the past week. She did not measure her temperature but does not complain of chills or night sweats. She has had no nausea, vomiting, or diarrhea. She is a nonsmoker. Her temperature is 101 F, with a blood pressure of 120/80 mm Hg, a heart rate of 88/min, and a respiratory rate of 22/min. Her oxygen saturation on room air is 92%. She has a slightly enlarged thyroid with no nodules or bruits. Her lung examination shows diffuse crackles bilaterally. The heart examination is normal, but a chest x-ray shows bilateral lobar consolidation. Which of the following would be the most appropriate for this patient?

(A) Thyroid-stimulating hormone (TSH)
(B) Chest CT scan
(C) CBC with manual differential, pan-cultures, and broad-spectrum antibiotics
(D) Bone marrow biopsy
(E) TSH-receptor antibody titers

Answer:

(C) CBC with manual differential, pan-cultures, and broad-spectrum antibiotics

Explanation:

This patient's hyperthyroidism is being treated with propylthiouracil (PTU); therefore, the patient is at risk for PTU-induced agranulocytosis. Any sign of illness in this patient must be quickly investigated for agranulocytosis. CBC would be the most appropriate initial test to see her neutrophil count. A patient with agranulocytosis may not show many systemic signs of infection. Similar to patients with neutropenia from cancer, a fever alone may be an indication to start immediate antibiotics. Due to a lack of neutrophils, the patient is at a high risk of bacterial and fungal infection. Although it is always appropriate to monitor the effect on the thyroid hormone levels, this is not as urgent as checking for the most life-threatening toxicity of PTU. A chest CT scan may be helpful later for evaluation of the abnormal lung examination and chest x-ray, but it would not be performed first. Bone marrow biopsy is never appropriate before checking the CBC.

Record # 19

Question/Fact:

A young man is found by the security guards outside the doors of the emergency room screaming and agitated. His blood pressure is 145/100 mm Hg, with a heart rate of 123/min, a temperature of 101.0 F, and a respiratory rate of 22/min. During the examination, the patient begins having a generalized seizure with urinary and fecal incontinence. The patient is intubated for airway protection, and the physical examination is continued. His pupils are dilated. His sodium is 143 mEq/L, with a creatinine of 0.9 mg/dL and a glucose of 126 mg/dL. Which of the following would be most useful for this patient?

(A) Propranolol
(B) Benzoylecgonine in the urine
(C) N-acetylcysteine
(D) Lumbar puncture and flumazenil

Answer:

(B) Benzoylecgonine in the urine

Explanation:

This patient's presentation is consistent with signs of cocaine intoxication. These patients can present with anxiety, tachycardia, hypertension, dilated pupils, agitation, muscular hyperactivity, and psychosis. The sustained hypertension may lead to intracranial hemorrhage, aortic dissection, or myocardial infarctions. The hypertension should not be treated with a pure beta-blocker alone because it may result in a paradoxical worsening of the hypertension due to an unopposed alpha-adrenergic effect. It should be treated with a vasodilatator such as nitroprusside or a combined alpha/beta agent, such as labetalol. N-acetylcysteine should be given for acetaminophen intoxication. Listeria infection is unlikely: This patient has no risk factors for it. Blood toxicology is not as specific as urine in most cases of qualitative drug screening, although it is better for qualitative tests. In cocaine intoxication, either cocaine or one of the metabolites, such as benzoylecgonine, are positive. This test is useful in this patient to establish a specific diagnosis. We have not yet truly proven why he is agitated.

Record # 20

Question/Fact:

A 45-year-old woman recently emigrated from Israel presents to the clinic with nasal discharge, weakness, nausea and vomiting, and decreased appetite for 3 weeks. She has had a low-grade temperature for a few days and has decided to come to the clinic today for antibiotics. On further questioning, she has had mild, diffuse, abdominal pain for the last month and has lost 5 lb as a result of having no appetite. She states that the abdominal pain is relieved by lying down and increases on exertion. She denies use of alcohol and smokes 1 pack of cigarettes per day but has had no desire for cigarettes over the past week. On physical examination, she is a healthy-appearing woman. Her temperature is 39.5 F, blood pressure is 135/75 mm Hg, heart rate is 78/min, and respirations are 18/min. She is anicteric and in no acute distress. There is some cervical lymphadenopathy, and the abdomen is mildly tender in the right upper quadrant.

Laboratory tests reveal the following: WBC 5,600/mm3, hemoglobin 10.8 mg/dL, hematocrit 38,8%, platelets 274,000/mm3, PT 28 seconds, INR 3.8, PTT 31 seconds, sodium 138 mEq/L, potassium 4.0 mEq/L, chloride 112 mEq/L, CO2 22 mEq/L, BUN 14 mg/dL, creatinine 0.8 mg/dL, and calcium 105 mg/dL. ALT is 382 U/L, AST is 327 U/L, and alkaline phosphatase is 121 U/L. Testing for hepatitis-C antibody is positive, hepatitis B e antigen (HbeAG) is negative, hepatis B e antibody (HbeAb) is negative, hepatitis B surface antigen (HbsAG) is negative, and hepatitis C virus (HCV) RNA is 580,000. What is the best treatment for this patient?

(A) Interferon--2b for six months
(B) Hepatitis B immunoglobulin (Ig) followed by hepatitis B virus (HBV) vaccine series
(C) Corticosteroids with morphine sulfate for pain relief
(D) Lamivudine
(E) Observation

Answer:

(A) Interferon--2b for six months

Explanation:

In patients with acute hepatitis C, early initiation of treatment with interferon will prevent the development of chronic hepatitis C in over 90% of persons. Lamivudine treats hepatitis e antigen-positive patients. Hepatitis B immunoglobulin (HBIG) is to prevent infection after an exposure to hepatitis-B surface-antigen-positive patients.

Record # 21

Question/Fact:

A 28-year-old female develops severe uterine bleeding with coagulation profile abnormalities eight hours after a successful delivery. She does not have any prior medical history, and the pregnancy was uncomplicated. She does not take any medications at home, except for multivitamins. The family history is unremarkable for any bleeding disorders. She has had tooth extractions in the past with no increase in bleeding.

On physical examination the patient presents as an anxious, nervous female, that looks her stated age. Her temperature is 97.8 F, blood pressure is 110/50 mm Hg, heart rate is 90/min, and the respiratory rate is 16/min. Her skin is pale. The uterus is enlarged, soft, and mildly painful on palpation. There are no external tears on vaginal exam. The amount of bleeding increases during palpation of the uterus.

Laboratory studies show the following results:

WBC 5,800/mm3; hemoglobin 9.8 g/dL; hematocrit 32.1 %, platelets 188,000/mm3; PT 12.4 seconds, INR 0.9, PTT 56 seconds. Bleeding time is normal. Fibrinogen 330 mg/mL; factor VIII: C level 22%.

The bleeding started three hours ago. During this time, the patient has received two units of packed red blood cells and six units of fresh frozen plasma (FFP), but the PTT remains elevated, and the bleeding still continues. Which test would be most useful in this situation?

(A) Von Willebrand's factor level
(B) Antiphospholipid antibody
(C) Russell viper venom (RVV) time
(D) PTT 1:1 mixing test
(E) Fibrin degradation products

Answer:

(D) PTT 1:1 mixing test

Explanation:

This patient developed factor VIII antibodies, which may happen postpartum or even sometimes without an obvious underlying cause. This can also occur in 15% of patients with factor VIII hemophilia, who have received infusions of fresh frozen plasma (FFP) or factor VIII replacement. In this disorder, the bleeding is usually severe, there is a decreased factor VIII level, and the PTT is prolonged. The fibrinogen level, PTT, and platelet count are not affected.

A plasma mixing test will show the presence of an inhibitor by the failure of normal plasma to correct the prolonged PTT. This test may require incubation for 2 to 4 hours. Factor VIII coagulant levels are low, which should not happen in von Willebrand's disease.

Hemophilia A is extremely unlikely in a woman because she would have to be homozygous recessive for the X-linked disorder. Factor VIII antibodies should be suspected in any patient with acquired severe bleeding and a prolonged PTT. The diagnosis is confirmed by mixing tests and by a failure of factor VIII concentrates to raise factor VIII:C levels.

Von Willebrand's disease is associated with mild mucosal bleeding. The measurement of von Willebrand's factor level will help you to distinguish between hemophilia A and von Willebrand's disease but won't explain why the coagulation profile was not corrected by transfusions of FFP.

Lupus anticoagulant is not associated with bleeding, unless a second disorder, such as thrombocytopenia or hypothrombinemia is present. Most commonly, it presents with thrombosis. Lupus anticoagulant also gives a prolonged PTT, and the mixing study will also fail to correct.

The Russell venom viper test is a more sensitive assay to demonstrate the presence of a lupus anticoagulant.

An antiphospholipid antibody is usually positive. Anticardiolipins are a related antiphospholipid antibody that can be detected by a separate assay.

Fibrin degradation products are elevated in DIC, which also presents with hypofibrinogenemia. D-dimer is the most sensitive of the fibrin-degradation products. The patient is usually seriously ill and has a low platelet count and elevation of the PT, as well as PTT. Bleeding may occur at any site, but spontaneous bleeding and oozing at venipuncture sites are important clues to the diagnosis.

Record # 22

Question/Fact:

A 35-year-old woman presents to the office with complaints of intermittent diarrhea over the past few weeks. She has lost 15 to 20 lb recently, despite a healthy appetite and normal food intake. She states that she frequently has loose, bulky, and foul-smelling stools. She denies any abdominal pain, the use of alcohol, and has no recent travel history. Past medical history is significant for insulin-dependent diabetes mellitus, diagnosed at age 14. At age 20, a perforated pyloric channel ulcer was treated surgically by a Roux en Y. Besides insulin, the patient takes no other medications.

On physical examination the vital signs are normal. She is a thin, pale-appearing woman. Her abdomen is soft and nontender with no hepatosplenomegaly. Her stool is negative for occult blood. She has diminished sensation over the bilateral lower extremities. Laboratory tests show: white blood cells: 7,500/mm3, hemoglobin 9.1 mg/dL, hematocrit 30%, platelets 450,000/mm3, mean corpuscular volume 105 μm3, vitamin B12 92 pg/mL (normal 330-1,025 pg/mL), and albumin 2.5 g/dL. The patient undergoes a 72-hour stool collection and excretes 21 grams of fat/24 hours (elevated). Stool culture is negative for parasites. What can the leading cause of malabsorption in this patient be attributed to?

(A) Pancreatic exocrine insufficiency
(B) Eosinophilic gastroenteritis
(C) Bacterial overgrowth secondary to Roux en Y surgery and diabetic enteropathy
(D) Pernicious anemia
(E) Crohn's disease

Answer:

(C) Bacterial overgrowth secondary to Roux en Y surgery and diabetic enteropathy

Explanation:

Bacterial overgrowth can cause diarrhea and malabsorption. Both a Roux en Y limb and diabetic enteropathy can result in bacterial overgrowth. The small intestine normally contains a small number of bacteria. Bacterial overgrowth results in malabsorption secondary to bacterial deconjugation of bile salts, leading to inadequate micelle formation. This will ultimately result in decreased fat absorption with steatorrhea. Microbes and bacteria uptake nutrients, thereby reducing absorption of vitamin B12 and carbohydrates. The proliferation of bacteria directly damages intestinal epithelial cells, as well as the brush border, impairing protein absorption. Passage of malabsorbed bile acids and carbohydrates into the colon leads to an osmotic and secretory diarrhea.

Record # 23

Question/Fact:

A 70-year-old woman has been brought to the emergency department for shortness of breath, cough, and lethargy for one day. The patient is confused. The daughter denies any problem of this type with the patient in the past, but she says cancerous polyps were found last year on colonoscopy. There has been progressive confusion and deterioration in her mental status over several years. On physical examination, the patient was found to be confused and has a temperature of 101 F, a blood pressure of 85/60 mm Hg, a pulse of 120/min, and a respiratory rate of 28/min. The chest examination shows decreased breath sounds with dullness to percussion on the right side at the base. The cardiac examination is normal. Laboratory studies reveal: white cell count 12,000/mm3, hematocrit 28%, platelets 400,000/mm3, sodium 135 mEq/L, bicarbonate 20 mEq/L, BUN 60 mg/dL, creatinine 3 mg/dL, and glucose 110 mg/dL. Urinalysis is positive for protein. Chest x-ray shows a right lower lobe infiltrate. Which of the following is correct about this patient?

(A) She has an approximately 30% chance to die with in 30 days
(B) Bronchoscopy is required
(C) The chance for Streptococcus pneumonia to be isolated is 80%
(D) Start ciprofloxacin
(E) Start vancomycin

Answer:

(A) She has an approximately 30% chance to die with in 30 days

Explanation:

The Pneumonia Outcome Research Team (PORT) scoring system is used to assess the risk of mortality on the basis of 19 clinical variables. The system stratifies patients into five mortality risk classes. This patient, with a score of >130, falls within the risk class V, which has a mortality risk between 27 and 31%. The following are the clinical variables for this patient and their scoring:

Age 70 (women: age - 10) = 60
Renal disease = 10
Hematocrit <30% = 10
Pleural effusion = 10
BUN >30 mg/dL = 20
Systolic pressure <90 mm Hg = 20
Neoplasm = 30

Total = 160

Patients with this class of mortality risk definitely need hospitalization. Streptococcus pneumoniae is the most common organism to be isolated in adults, but it is isolated in far less than 80% of cases. Prospective studies fail to identify a specific microbiologic cause of community-acquired pneumonia (CAP) in >50% of cases. Sputum Gram stain and culture should be done on all patients who are hospitalized. Bronchoscopy is not necessary unless the patient is severely ill, and sputum analysis fails to identify a specific causative organism. Ciprofloxacin is not an appropriate choice of medication for CAP; it has inadequate pneumococcal coverage. Vancomycin is used in pneumonia only if the causative organism has been definitely identified as penicillin-resistant pneumococcus. The other criteria for a serious pneumonia are: the presence of liver or heart disease, a pulse of >125/min, a sodium of <130 mEq/L, a glucose of >250 mEq/L, a pO2 of <60 mm Hg, a fever >40 C, and confusion.

Record # 24

Question/Fact:

A 28-year-old man with a history of renal insufficiency comes to your office with the gradual onset of mild lower back pain that has been radiating down to his thighs over the last two months. He also complains of bilateral shoulder and knee pain that improves with exercise. The patient states that his back is slightly stiff in the morning and that this stiffness is worsened by rest and relieved when he walks. He has never had any back pain before. On physical examination, he is afebrile. There is no local lower back tenderness, and he has a minimally decreased range of motion in the lumbar part of the spine. His rheumatoid factor is negative, and the ESR is 40 mm/h. Plain x-rays of the spine and pelvis are normal. Which of the following is the most appropriate management at this time?

(A) Hydroxychloroquine
(B) Prednisone
(C) Indomethacin
(D) Celecoxib
(E) Physical therapy

Answer:

(E) Physical therapy

Explanation:

This patient presents with what is most likely ankylosing spondylitis (AS). This is a chronic inflammatory disease of the joints of the axial skeleton, manifested by pain and progressive stiffness of the spine. He has had this pain for only two months, and the MRI will most likely not show any changes in the sacroiliac joints. He has very mild disease and no evidence as of yet of an anatomic abnormality. In fact, he is still missing many of the firm diagnostic criteria for AS, such as >3 months of symptoms, limited thoracic motion, iritis, and radiological evidence of sacroiliitis. Eventually, erosions and sclerosis of sacroiliac joints will become evident on radiographs. The term "bamboo spine" has been used to describe the late radiographic appearance of the spinal column. This patient has a history of renal insufficiency, and NSAIDs or COX-2 inhibitors may worsen his renal function and are thus contraindicated in this case. He now has only mild lower back pain with slight stiffness and will benefit from physical therapy, which might prevent axial skeleton deformity.

The onset of AS is usually gradual with intermittent bouts of back pain that may radiate down the thighs. The disease progresses in a cephalad direction, and back motion becomes progressively more limited. Transient acute arthritis of peripheral joints occurs in approximately 50% of cases, and permanent changes in the peripheral joints are seen in about 25%. This is most common of the hips, shoulders, and knees.

Record # 25

Question/Fact:

A 30-year-old woman in her thirtieth week of pregnancy comes in for her monthly evaluation by her obstetrician. As a part of her routine evaluation, she provides a urine specimen to the nurse. She has urinary frequency of 8 to 10 trips to the bathroom per day. She denies dysuria, hematuria, or fever. Her temperature is 99 F, with a pulse of 90/min and a blood pressure of 110/70 mm Hg. The examination reveals a gravid uterus compatible with 30 weeks of gestation. Her genital examination reveals no discharge or erythema. The urinalysis reveals 10 to 25 white cells/hpf with numerous bacteria but no red cells. What is your next step at this time?

(A) Do nothing
(B) Trimethoprim/sulfamethoxazole
(C) Ampicillin
(D) Gatifloxacin
(E) Renal ultrasound
(F) Ciprofloxacin

Answer:

(C) Ampicillin

Explanation:

This patient is presenting with a urinary tract infection (UTI) during pregnancy. Though minimally symptomatic at this time, it is important to treat all urinary infections during pregnancy. There is a 20 to 40% risk of developing pyelonephritis if untreated. A diagnostic study, such as a renal ultrasound, is not appropriate at this time. Of the antibiotics listed, only ampicillin is appropriate. Nitrofurantoin or cephalosporins, such as cephalexin, are safe to use in pregnancy but are not listed in the answer choices. Sulfa-based drugs can predispose to hyperbilirubinemia and kernicterus by interfering with bilirubin binding and should be avoided in the later trimesters. Fluoroquinolones, like gatifloxacin and ciprofloxacin, are potentially teratogenic upon the skeletal system and cartilage of the fetus.

Record # 26

Question/Fact:

A 78-year-old man with a history of coronary artery disease, congestive heart failure (CHF), and hyperlipidemia was admitted to CCU three days ago with a diagnosis of non-Q-wave myocardial infarction (MI). He was transferred to a regular floor yesterday after he was stabilized.

His current medications include aspirin, metoprolol 25 orally twice a day, nitroglycerin, furosemide 40 mg orally twice a day, and simvastatin. Physical examination shows a pulse of 82/min, a respiratory rate of 16/min, and a blood pressure of 112/62 mm Hg. There are minimal bibasilar crackles on lung examination, an S4 gallop on cardiac examination, and a trace edema in the extremities. Echocardiogram shows decreased left ventricular systolic function. You start him on captopril 6.25 mg every eight hours and double the dose with each additional dose until you reach the minimal effective dose of 50 mg three times a day. The following day, the nurse informs you that his blood pressure dropped to 95/49 mm Hg, with a pulse of 94/min, and she is hesitant to give any antihypertensive medications. What would be the most appropriate response?

(A) Discontinue metoprolol
(B) Discontinue captopril
(C) Reduce the dose of furosemide
(D) No intervention because his blood pressure drop is transient
(E) Hold all medications

Answer:

(C) Reduce the dose of furosemide

Explanation:

ACE inhibitors such as captopril have become standard therapy for CHF because they have been shown to decrease mortality. They should be started with small doses and titrated up as tolerated because of a possible hypotensive effect. The final dosage should be 50 mg orally every 8 hours. This is the minimum needed to achieve the needed effect on relieving afterload. Remember, however, that there is virtually no reason to use a cumbersome three-times-a-day medication such as captopril for an outpatient when drugs such as ramipril, quinapril, lisinopril, and fosinopril can be used once a day and with far greater adherence.

This patient developed his hypotensive episode a full day after being on a higher dose of the ACE inhibitor. The hypotensive episode may therefore not be directly related to just the use of the ACE inhibitor. The diuretic dose may need downward adjustment or be withheld for 24 hours. Besides having only minimal signs of fluid overload, the question is making sure you know that it is more important to first remove drugs that don't have a definite effect on lowering mortality. In addition, reducing the dose of Lasix to 20 or 40 mg once a day will not result in any harm to the patient.

Record # 27

Question/Fact:

A 45-year-old man has had dysphagia of increasing severity over the past year. He has recently lost 5 lb. The upper endoscopy shows distal erythema of the esophageal mucosa and resistance to the passage of the endoscope at the esophagogastric junction. No anatomical lesion is seen. Esophageal motility shows lack of peristalsis in the body of the esophagus and a high-pressure lower esophageal sphincter with incomplete relaxation with swallowing. Which of the following treatments would NOT be appropriate for this patient?

(A) Pneumatic dilatation
(B) Botulinum toxin injection
(C) Surgical myotomy
(D) Anticholinergic agents
(E) Calcium-channel blockers

Answer:

(D) Anticholinergic agents

Explanation:

Achalasia is an idiopathic disorder characterized by disturbed esophageal motility and high pressure of the lower esophageal sphincter, with incomplete relaxation during normal swallowing. Most patients with achalasia are treated with pneumatic dilatation. Botulinum toxin and calcium-channel blockers can be attempted with some success. The surgical Heller myotomy is the most effective surgical technique. Anticholinergic agents only exacerbate the disease.

Record # 28

Question/Fact:

A 72-year-old man is admitted to the hospital from a nursing home for a pressure ulcer of his ankle. The x-ray of the foot shows bone destruction consistent with osteomyelitis. A biopsy of the bone reveals Escherichia coli that is sensitive to every antibiotic tested. What is the most appropriate therapy?

(A) Intravenous piperacillin-tazobactam for six weeks
(B) Intravenous ampicillin-sulbactam for six weeks
(C) Oral amoxicillin-clavulanic acid for six weeks
(D) Oral ciprofloxacin for six weeks
(E) Intravenous ceftazidime for six weeks

Answer:

(D) Oral ciprofloxacin for six weeks

Explanation:

Although all of the medications listed will be effective for a sensitive E. coli, the most convenient therapy is oral ciprofloxacin. Oral quinolones, specifically ciprofloxacin, are equal in efficacy to intravenous therapy.

Record # 29

Question/Fact:

A 50-year-old man is brought in by an ambulance to the emergency department because of increased shortness of breath for the past two weeks. He feels short of breath on exertion for the last two years, uses at least two pillows at night, and denies chest pain or palpitations. He has no history of ischemic heart disease. He is not compliant with his medications and forgets to take his "water pills." He has five vodka martinis every night. The patient has been smoking one pack of cigarettes a day for the past 30 years. Last month he was treated in another hospital for alcohol withdrawal symptoms.

On physical examination, the patient is lying in bed and is slightly short of breath. His temperature is 97.0 F, heart rate is 78/min, respiratory rate is 22/min, and blood pressure is 150/80 mm Hg. The neck veins are distended. There is cardiomegaly and an S3 gallop. On lung auscultation, there are crackles at both bases. The liver edge is palpated 2 cm below the right costal margin. There is 1+ bilateral leg edema.

EKG shows low QRS voltage, nonspecific ST-segment and T changes. The chest x-ray shows cardiomegaly and mild pulmonary congestion. Left ventricular dilation is found by echocardiogram.

What is your choice of therapy at this time?

(A) Captopril, furosemide, beta-blockers
(B) Losartan, furosemide, coumadin
(C) Captopril, spironolactone, digoxin
(D) Captopril, furosemide, digoxin, coumadin

Answer:

(A) Captopril, furosemide, beta-blockers

Explanation:

This patient presents with dilated cardiomyopathy and displays signs of biventricular heart failure. Chronic alcohol abuse is one of the most frequent causes of dilated cardiomyopathy. The management is similar to that of congestive heart failure related to ischemia. The offending agent should be discontinued. Initial treatment usually consists of diuretics, ACE inhibitors, and beta-blockers. The addition of digoxin depends of presence of decreased left ventricular function and the persistence of symptoms despite the use of ACE inhibitors, diuretics, and beta-blockers. Chronic anticoagulation must be considered but should only be used if there were evidence of thrombosis. In addition, coumadin should be used with extreme caution in an alcoholic. Angiotensin-receptor blockers are indicated when patients cannot tolerate ACE inhibitors because of adverse effects, such as a cough.

Record # 30

Question/Fact:

A 68-year-old man with a history of hypertension is brought to your office with complaints of progressive memory loss and poor concentration over the last four months. According to the patient's wife, he has become forgetful, irritable, and emotionally labile. He is apathetic and has little spontaneous speech. Recently, the patient developed urinary incontinence and gait impairment. He has to take very short steps to walk; however, there is no shuffling gait. His funduscopic examination is normal. There is mild bradykinesia but no tremor or rigidity of the extremities. Lumbar puncture is performed in the office and led to an improved gait. Which of the following is the most appropriate management for this patient?

(A) Ventriculoperitoneal shunting
(B) Bromocriptine
(C) Aspirin
(D) Donepezil
(E) Penicillin

Answer:

(A) Ventriculoperitoneal shunting

Explanation:

This patient presents with normal-pressure hydrocephalus (NPH). NPH should be considered in mildly demented patients with gait disturbances and urinary incontinence. Mild, generalized slowness of movement and thought are frequently present in NPH and may be due to excessive cerebrospinal-fluid production or insufficient absorption. Large-volume lumbar puncture can lead to an improvement in the gait. Patients with NPH are more likely to benefit from ventriculoperitoneal shunting if there has been a demonstrated improvement in symptoms after a lumbar puncture. The lumbar puncture is not absolutely essential. If a patient has all the classic symptoms of NPH, you can go straight to ventriculoperitoneal shunting.

The essential features of Parkinson's disease (PD), such as an expressionless face, poverty and slowness of movement, and shuffling gait are absent in this patient. Multi-infarct dementia is not likely in this patient because his course has been gradual and progressive rather than punctuated in a step-like progression. Therefore, aspirin is not useful. Treatment with bromocriptine is used in PD to delay the need for levodopa, not in NPH. Donepezil is useful in Alzheimer's disease. Alzheimer's disease takes years to become severe and would never lead to urinary incontinence or a gait abnormality over four months, such as in this patient's case. Penicillin is used for neurosyphilis. Neurosyphilis could present with the memory loss and even the abnormal gait seen in this patient because of the posterior column disease, but it would not improve with a lumbar puncture.

Record # 31

Question/Fact:

A 72-year-old man with a history of multiple admissions to the hospital for acute cholecystitis undergoes elective cholecystectomy. His recovery period is unremarkable until the day before discharge, when he suddenly begins to experience palpitations. He denies chest pain. An EKG reveals his baseline right bundle branch block (RBBB) and a new atrial flutter at a rate of 120 to 140/min. The patient is started on anticoagulation with heparin. He remains in atrial fibrillation over the next two days. His chest x-ray is normal, and laboratory studies demonstrate normal potassium, magnesium, and thyroid-stimulating hormone. Transesophageal echocardiogram was negative for intracardiac thrombi. The decision was made to proceed with chemical cardioversion.

The patient has a history of allergy to cephalosporins and aspirin. He is given intravenous procainamide. During the infusion, the telemetry reveals a rate of 230/min with wide QRS complexes. He is found to be pulseless. CPR is started, and he is defibrillated with 100 J, which restores sinus rhythm that then degenerates into atrial fibrillation.

What could have prevented this reaction?

(A) If the infusion of procainamide had been administered slower
(B) If the patient's allergy to procainamide had been known
(C) If quinidine had been used instead of procainamide
(D) If pretreatment before procainamide had been undertaken with propranolol, digoxin, or verapamil

Answer:

(D) If pretreatment before procainamide had been undertaken with propranolol, digoxin, or verapamil

Explanation:

The most likely explanation for his rhythm was one-to-one conduction of atrial flutter through an AV node. This could have been prevented through an adequate AV nodal blockade before administration of procainamide. Quinidine, which could have resulted in the same response, also requires an adequate AV nodal blockade before its administration. Both procainamide and quinidine actually speed conduction through the AV node. Drug allergies generally do not result in a rhythm disturbance. When procainamide is administered too rapidly, the abnormal response is hypotension, not progression to a wide complex tachycardia.

Record # 32

Question/Fact:

A 52-year-old man is brought to the hospital with generalized weakness, shortness of breath on minimal exertion, and swelling of the extremities, progressing over the last two months. He was recently diagnosed with non-Hodgkin's lymphoma and was treated with cyclophosphamide and prednisone. He is in mild respiratory distress. He has decreased breath sounds on the right side, with dullness to percussion, and absent tactile fremitus over the same area. There is prominent nonpitting edema of the extremities and abdominal wall. The chest x-ray shows a large pleural effusion on the right side and widening of the mediastinum. At thoracentesis, 800 mL of milky fluid is obtained. Pleural fluid analysis shows: glucose 68 mg/dL, protein 5.6 g/dL, LDH 188 mg/dL, cholesterol 80 mg/dL, white cells 2,500/mm3, with neutrophils 36% and lymphocytes 62%. The serum protein is 6.2 g/dL, and the LDH is 82 mg/dL. What is the next best step to determine the nature of this effusion?

(A) Measure serum triglyceride concentration
(B) Obtain pleural-fluid cytology results
(C) Perform pleural biopsy
(D) Evaluation of supernatant
(E) Bronchoscopy with endobronchial biopsy

Answer:

(D) Evaluation of supernatant

Explanation:

This patient presents with chylothorax most likely resulting from invasion of the mediastinum by the lymphoma. In general, chylothorax is caused by the leakage of lymph from the thoracic duct. This is usually related to malignancy in 50%, thoracic surgery in 20%, or trauma in 5%. The triad of slow-growing yellow nails, lymphedema, and pleural effusion (yellow nail syndrome) is due to hypoplastic or dilated lymphatics. The milky appearance of the fluid may be confused with a cholesterol effusion or an effusion with many lymphocytes. The first step in the evaluation of a milky effusion is an evaluation of the supernatant. If, after being centrifuged, the fluid still appears milky, this usually rules out empyema as a cause of the milky appearance. The best diagnostic test for chylothorax is the presence of a triglyceride concentration >110 mg/dL in the pleural fluid. Serum triglyceride levels don't help. For those patients without an obvious cause of the disease, CT scanning of the chest or a lymphangiogram may help in the diagnosis. Treatment includes drainage of the pleural space by the placement of a chest tube. Decreased oral fat intake and the use of medium-chain triglycerides can also be useful. Medium-chain triglycerides are absorbed directly into the portal circulation and do not go through the normal lymphatic drainage, such as the thoracic duct. Thoracic duct ligation should be considered in trauma and in those with malignancy as the primary cause of the effusion.

Evaluation of the supernatant for cholesterol crystals is suggested to rule out pseudochylothorax when the effusion has been present for a long period of time. In the case in this question, the rapid progression of symptoms suggests a relatively recent onset of pleural effusion, and it is justified to request evaluation of the triglyceride level first. Pleural cytology, bronchoscopy, and pleural biopsy will not determine the nature of effusion. Even if they are positive, they do not tell you that there is an obstruction of the lymphatic system.

Record # 33

Question/Fact:

A 72-year-old man reports one month of episodic palpitations. He is not short of breath. The patient has a past medical history of stable angina and hypertension. A physical examination performed during the episode of palpitations shows a blood pressure 160/90 mm Hg, normal jugular venous pressure, and irregularly irregular heart sounds with a heart rate of 82/min. Mild bibasilar crackles are present. Echocardiography shows mild to moderate left ventricular hypertrophy and an ejection fraction of 50%.

Which of the following is true concerning this patient?

(A) Antiarrhythmic agents should be started first.
(B) Anticoagulation must be done only prior to cardioversion.
(C) Chronic coumadin should be started for every patient with atrial fibrillation.
(D) A beta-blocker, calcium-channel blocker, or digoxin should be started prior to using to lC and lA agents, as well as dofetilide.
(E) Amiodarone has the same efficacy rate in maintaining sinus rhythm after conversion of atrial fibrillation as other antiarrhythmic agents.

Answer:

(D) A beta-blocker, calcium-channel blocker, or digoxin should be started prior to using to lC and lA agents, as well as dofetilide.

Explanation:

In the absence of severe cardiovascular compromise, slowing of ventricular rate becomes the initial therapeutic goal. This may be most rapidly accomplished with beta-adrenergic blockers and/or calcium-channel blockers. Both slow conduction within the AV node. Conversion to sinus rhythm with antiarrhythmic medications may then be attempted.

Patients who have had atrial fibrillation for >48 hours should be anticoagulated for 3 to 4 consecutive weeks before electrical or chemical cardioversion. Both pharmacological and electrical conversion of atrial fibrillation to sinus rhythm are associated with transient atrial stunning or electromechanical dissociation, in which the return of effective atrial mechanical function lags behind sinus activity for as long as 7 days. Recognition of this phenomenon supports the need for maintaining effective anticoagulation (INR 2 to 3) for at least 3 to 4 weeks after conversion. For patients with paroxysmal atrial fibrillation, anticoagulation should be maintained until a stable sinus rhythm has been present for several months. This can be maintained indefinitely if sinus rhythm cannot be maintained despite antiarrhythmic therapy and if the patient has a high risk for stroke, such as hypertension, mitral valve disease, heart failure, or diabetes. Even in the absence of these risk factors, patients above the age of 60 have an increased risk for stroke, and anticoagulation with warfarin should be considered. Younger patients without any of these risk factors can be maintained on aspirin alone.

Antiarrhythmic medications in either oral or intravenous form are modestly effective in restoring sinus rhythm. When antiarrhythmic agents, such as those in class lA (quinidine, procainamide, or disopyramide) or the flecainide-like agents (type 1C), are used, it is important to increase AV node refractoriness prior to administering such drugs. They have a vagolytic effect and speed up the heart rate.

Amiodarone has the highest efficacy rate in maintaining sinus rhythm after conversion of atrial fibrillation and also the lowest incidence of proarrhythmia (1 to 2% compared with 5 to 10% for other agents). Amiodarone is particularly effective in those with left ventricular dysfunction and has a much better efficacy in the setting of left ventricular dysfunction.

Record # 34

Question/Fact:

A 45-year-old man presents to the emergency department with the chief complaint of upper abdominal pain, vomiting, and blurred vision, which started two hours ago after ingesting an unknown liquid. He has a history of alcoholism. The patient appears lethargic. His blood pressure is 100/60 mm Hg, with respirations of 24/min, and a temperature of 98.8 F. His pupils are 3 mm and reactive to light. Funduscopic examination reveals hyperemia of the optic disk bilaterally. There is no unusual odor of the patient's breath. Abdominal examination showed diffuse tenderness without guarding. The vomitus and stool are negative for occult blood. Neurological evaluation revealed no focal deficits. Laboratory studies reveal: sodium 136 mEq/L, potassium 4.1 mEq/L, chloride 97 mEq/L, bicarbonate 14 mEq/L, BUN 18 mg/dL, creatinine 1.0 mg/dL, and calcium 9.4 mg/dL. An arterial blood gas shows: pH 7.33, pCO2 33 mm Hg, pO2 93 mm Hg, and a bicarbonate of 15 mEq/L. The urinalysis is negative for glucose and protein, with no ketones or crystals. His osmolar gap is 12 mOsm/kg. Which of the following diagnosis is the most likely?

(A) Ethylene glycol intoxication
(B) Methanol intoxication
(C) Ethanol intoxication
(D) Isopropyl alcohol intoxication

Answer:

(B) Methanol intoxication

Explanation:

Methanol intoxication is characterized by the presence of central nervous system (CNS) depression and acidosis but also by the absence of ketosis or an abnormal odor of the breath. Shortly after the ingestion of methanol, patients usually appear "drunk." The serum osmolality is usually increased, but acidosis is often absent early. After several hours, there is metabolism to toxic organic acids, leading to a severe anion-gap metabolic acidosis, tachypnea, confusion, convulsions, and coma. Methanol intoxication frequently causes blurred vision and hyperemia of the optic disc.

Ethanol intoxication is characterized by the presence of CNS depression and an abnormal odor of the breath, as well as acidosis and ketosis. Isopropyl alcohol intoxication is characterized by the presence of CNS depression, ketosis, and a breath odor, yet a normal anion gap. Acetone is the toxic metabolite. Hemorrhagic tracheobronchitis and gastritis are characteristic findings. Ethylene glycol intoxication is characterized by the presence of acidosis and CNS depression. Nephrotoxicity, hypocalcemia, deposition of calcium oxalate crystals in the urine, and renal failure are characteristic findings in this intoxication.

Record # 35

Question/Fact:

A 58-year-old man is seen in the emergency department with a chief complaint of palpitations following exercise and when he becomes anxious. He is in no apparent distress and denies chest pain or shortness of breath. The patient states that aside from the palpitations, he is doing well. The patient has a past medical history of a cardiac defect and acute, gouty arthritis for which he was prescribed a tapering dose of indomethacin. Physical examination shows normal vital signs, a parasternal lift, and clear lungs with no murmurs.

The patient had a heart operation when he was a child. The patient cannot recall why he was operated on, but he does state that before the operation he would become short of breath and squat while playing with his siblings. An EKG is ordered. During the test, the patient becomes agitated, and the EKG displays supraventricular tachycardia, which stops spontaneously.

What will this patient eventually require?

(A) Cardioversion
(B) Catheter ablation
(C) Amiodarone
(D) Verapamil
(E) Pulmonary valve replacement

Answer:

(B) Catheter ablation

Explanation:

This patient is experiencing supraventricular tachycardia as a result of previous repair of tetralogy of Fallot. Tetralogy of Fallot is the most common form of cyanotic congenital heart disease after 1 year of age, with an incidence approaching 10% of all forms of congenital heart disease. The defect is due to anterocephalad deviation of the outlet septum, resulting in four possible features: 1) ventricular septal defect, 2) overriding aorta, 3) pulmonary valve stenosis, and 4) consequent right ventricular hypertrophy. To reach adulthood, most patients will have had surgery, either palliative, or more commonly, reparative. A few patients, however, will present as adults with an uncorrected tetralogy of Fallot. Natural survival into the fourth decade is rare (approximately 3%).

After intracardiac repair, over 85% of patients are asymptomatic on follow-up. Palpitations from atrial and ventricular tachycardias, with or without dizziness or syncope, and dyspnea from progressive right ventricular dilation secondary to chronic pulmonary regurgitation occur in 10 to 15% of patients at 20 years after initial repair. Physical examination may reveal a parasternal right ventricular lift from right ventricular dilation. Ventricular tachycardia can arise at the site of the right ventriculotomy, from ventricular septal defect (VSD) patch suture lines, or from the right ventricular outflow tract. Recurrent episodes of supraventricular tachycardia will eventually require catheter ablation of the site of reentry to terminate this patient's dysrhythmias. Verapamil and amiodarone can worsen the rhythm disturbance.

Record # 36

Question/Fact:

A 77-year-old man visits his physician for a general checkup. The patient denies the use of alcohol and states that after a 40-pack-year smoking history, he has finally quit and has not had a cigarette for the past five months. On physical examination, the vital signs are normal. The patient does not appear to be in any distress and there are no palpable lymph nodes on head and neck examination. Chest is clear to auscultation bilaterally. Cardiac examination is normal, and there are no focal neurologic deficits. Chest x-ray shows a 2-cm solitary pulmonary nodule with spiculation located in the right upper lobe with dense calcification. Which of the following factors increase the probability that the lung nodule is malignant?

(A) Presence of spiculation or lobulation
(B) Dense calcification
(C) No enlargement of nodule after 12 months
(D) Upper lobe location
(E) Decreased degree of enhancement on contrast-enhanced CT scan

Answer:

(A) Presence of spiculation or lobulation

Explanation:

A solitary pulmonary nodule is a parenchymal lesion of the lung that is 3 cm or less in diameter and does not invade other structures. The probability that a nodule is malignant is dependent on the following factors:

• Large size of the nodule
• Presence of spiculation or lobulation
• Age of the patient
• • • • • •
The presence of dense calcification and the absence of significant enlargement over a period of 12 to 24 months indicate that a solitary pulmonary nodule is benign. The average malignant nodule will double in volume in 18 months. On contrast-enhanced CT, an increased degree of enhancement correlates with an increased probability of malignancy. Lobe location is not precise enough to be useful in determining the likelihood of malignancy.

Record # 37

Question/Fact:

A 34-year-old man comes to your office for evaluation of a rash on his back. He has a 7-cm, circular, erythematous rash with central clearing. There is a small punctum in the center of the rash. He lives in Connecticut and has recently been camping. What is the next step in management?

(A) Doxycycline
(B) Skin biopsy
(C) Serologic testing
(D) Reassurance

Answer:

(A) Doxycycline

Explanation:

If a patient presents with a classic erythema migrans rash consistent with Lyme disease, there is no point in doing serologic testing. You should simply start therapy. The patient has been camping in an endemic area. He has a round, erythematous rash with central clearing, which is consistent with Lyme. This clinical presentation is more specific than the serology. Even if the serology were negative, you should still treat him anyway. Skin biopsy is only necessary in equivocal cases.

Record # 38

Question/Fact:

A 55-year-old man with a history of diabetes and hypertension is admitted after a syncope episode. He states that he has had two other syncopal episodes in the past. Both of these were moderately rapid in onset. His physical examination is unremarkable. An EKG is done and shows evidence of left ventricular hypertrophy. This is confirmed on echocardiogram. His ejection fraction is 55%. Tilt-table testing shows a drop in systolic blood pressure of 20 mm Hg without changes in heart rate. What would be the most appropriate action for this patient?

(A) Start beta-blockers
(B) Start an alpha-agonist (midodrine)
(C) Cardiac catheterization
(D) Stress test
(E) Event recorder

Answer:

(B) Start an alpha-agonist (midodrine)

Explanation:

The patient has autonomic dysfunction, resulting in orthostatic hypotension, as demonstrated by the abnormal tilt testing. Abnormal results include hypotension, bradycardia, or both. Patients with orthostatic hypotension-producing symptoms can be successfully treated with alpha-agonists such as midodrine. Syncope associated with left ventricular dysfunction or nonsustained ventricular tachycardia is best treated with beta-blockers. Beta-blockers are also used in vasovagal syncope. They appear to have a role in suppressing the initial burst of tachycardia, which initiates a reflex bradycardia, resulting in hypotension. Cardiac catheterization is useful once an echocardiogram shows evidence of structural heart disease (e.g., aortic stenosis). Event recording is not particularly useful in patients with an abrupt onset of symptoms. The test has a low sensitivity, and the rapid onset of symptoms often prevents recording of the event. Stress testing is useful to detect ischemia and is not particularly useful in the evaluation of syncope.

Record # 39

Question/Fact:

A 35-year-old man with a past medical history of AIDS is admitted for fulminant herpes zoster and is started on intravenous Acyclovir. Two days later, the patient has multiple episodes of hematemesis and is transferred to the intensive care unit, where he is given four units of packed red blood cells. The following day, an upper endoscopy reveals esophagitis. He starts to improve, but two days later he develops jaundice. His labs show a rise in his creatinine from 1.2 to 2.5 mg/dL. His 24-hour urine output drops from 1,200 to 350 mL. Physical examination reveals jaundice. Laboratory studies reveal:

Potassium 5.6 mEq/L, bicarbonate 24 mEq/L, BUN 36 mg/dL, creatinine 2.5 mg/dL, hematocrit 32%. The urinalysis is dipstick-positive for blood, and there are pigmented tubular casts with no crystals or bilirubin. No red cells are seen on microscopic examination. The urine sodium is elevated, and the fractional excretion of sodium is >1%.

What is the next best management?

(A) Stop Acyclovir
(B) Repeat ABO testing of the patient's blood
(C) Coombs' test
(D) Hemodialysis
(E) Thiazide diuretic

Answer:

(C) Coombs' test

Explanation:

Transfusions with mismatched blood can result in pigment nephropathy. Hemoglobinuria as a result of hemolysis is directly toxic to kidney tubules. The patient seems to have a mismatch of the minor blood group antigens, such as Rh, Kell, Duffy, Louis, and Kidd. The clue to this is a delay in the development of jaundice until the following day. Coombs' test will tell us if there is an autoimmune hemolysis occurring. Repeating the crossmatch of minor antigens, not the ABO type, is appropriate.

Major blood-group antigen mismatch, such as an ABO incompatibility, would have given severe, immediate symptoms. Treatment involves volume repletion and the occasional use of mannitol and bicarbonate to alkalinize the urine and protect the kidney tubule. Thiazides would not be the right kind of diuretic to use. Bilirubin is absent from the urine because hemolysis elevates the level of indirect bilirubin. Indirect bilirubin is bound to albumin and does not filter at the glomerulus.

Acyclovir might be associated with crystals in the urine and usually gives a nonoliguric form of renal failure. Acyclovir is unlikely to give blood or hemoglobin in the urine. This patient's renal failure is not severe enough to need dialysis.

Record # 40

Question/Fact:

A 51-year-old man who recently emigrated from Russia comes for his first evaluation to the clinic. He does not have any complaints and has always considered himself to be a healthy person. On physical examination, he has a diminished S1 and a holosystolic murmur, which is high-pitched and blowing in character. It is best heard at the apex and radiates to the axilla. Carotid upstrokes are sharp, and the cardiac apical impulse is displaced laterally and is brisk and hyperdynamic. The EKG reveals left atrial enlargement and left ventricular hypertrophy. The echocardiogram shows severe mitral regurgitation (MR), a dilated left atrium, and hypertrophy and dilation of the left ventricle. There is decreased left ventricular systolic function with an ejection fraction of 45 to 50%. What would you recommend to this patient?

(A) Transesophageal echocardiogram as a part of a preoperative work-up
(B) Start digoxin
(C) Repeat echocardiogram in six months
(D) Consider surgery if symptoms of congestive heart failure (CHF) develop in the future

Answer:

(A) Transesophageal echocardiogram as a part of a preoperative work-up

Explanation:

The patient in this case has mitral regurgitation (MR) based on a holosystolic murmur radiating to the axilla. On the basis of the asymptomatic presentation, it is most likely chronic. Later in the course of the disease, exercise intolerance and exertional dyspnea usually develop first. Orthopnea and nocturnal dyspnea can develop as MR progresses. Fatigue can be caused by diminished cardiac output. With development of left ventricular dysfunction, further symptoms of CHF become manifest. Long-standing MR can cause pulmonary hypertension with symptoms of right ventricular failure. Atrial fibrillation can occur as a consequence of left atrial dilatation. When left ventricular function is preserved, carotid upstrokes are sharp, and the cardiac apical impulse is brisk and hyperdynamic. With the development of left ventricular dilatation, the apical impulse is displaced laterally. A right ventricular heave and a palpable P2 can be present if pulmonary hypertension has developed.

Most patients who have moderately severe to severe MR and are symptomatic should be considered for elective surgical treatment. The treatment of patients with minimal or no symptoms but severe MR is more complex. The key is to identify patients before contractile dysfunction of the left ventricle becomes irreversible. Echocardiography parameters can be useful in ascertaining whether the patient needs surgical treatment. Given the altered preload and afterload, the ejection fraction should be normal. Thus, an ejection fraction less than 50% implies marked left ventricular contractile dysfunction. Such patients should be referred for surgery even if they are asymptomatic. Transesophageal echocardiogram allows better visualization of leaflet motion and a color jet direction, and so it is useful to define the mechanism of MR and plan the surgery.

The role of medical therapy in the management of asymptomatic, chronic MR is not well established. There is no evidence that digoxin can delay progression of the disease or prevent ventricular dysfunction. Watchful waiting until serious symptoms develop in patients with severe mitral regurgitation carries an increased risk of the development of severe left ventricular dysfunction and thus a poor prognosis

The major point in this case is that once the ejection fraction drops or anatomic abnormalities in the heart develop, surgical repair of the valve is indicated, even if there are no symptoms.

Record # 41

Question/Fact:

A 75-year-old woman is admitted to the hospital with generalized weakness, fatigue, and irritability of increasing severity for the past two months. Six months ago, the patient was found to have a mass of the head of the pancreas consistent with pancreatic cancer. She refused further diagnostic work-up or treatment. She has lost 25 pounds since then.

On physical examination, her blood pressure is 110/70 mm Hg, heart rate is 98/min, and the respiratory rate is 18/min. The patient presents as a thin female with pale skin and conjunctiva. Her heart examination shows a II/VI systolic murmur. The rectal examination reveals hemorrhoids and is heme-negative. Laboratory studies reveal the following: WBC 8,900/mm3; hemoglobin 8.7 mg/dL; hematocrit 26.8%; platelets 173,000/mm3; MCV 76 FL; reticulocyte count 1.0%; serum iron 32 µg/dL (normal 60-160 µg/dL); ferritin 140 ng/mL; TIBC low.

What treatment would be the best choice for this patient?

(A) Periodic blood transfusions
(B) Erythropoietin
(C) Ferrous sulfate
(D) Vitamin B12 and folic acid

Answer:

(A) Periodic blood transfusions

Explanation:

This patient most likely has the anemia of chronic disease. The diagnosis is suggested by finding a low serum iron, low TIBC, and a normal or increased serum ferritin. Red blood cell morphology would be nondiagnostic, and the reticulocyte count is reduced. Both iron deficiency and the anemia of chronic disease can give microcytic, hypochromic cells. A mistaken diagnosis of iron-deficiency anemia may be made if emphasis is placed on the reduced serum iron level.

Purified recombinant erythropoietin has been shown to be effective for the treatment of anemia of renal failure. There will be no effect of erythropoietin in patients who have their anemia from malignancy. Because this is not iron deficiency, ferrous sulfate will not help. All you can do in a case like this is transfuse them as often as they need it.

Record # 42

Question/Fact:

A 32-year-old woman was admitted with generalized weakness and blurred vision for the last two weeks. She was diagnosed with HIV last year. Her CD4 count at that time was 105/μL. She was started on zidovudine, lamivudine, and ritonavir/lopinavir. Her last CD4 count six months ago was 50/μL, and her viral load was undetectable at that time. Because she felt she was doing so well on the medications, she decided to try a holiday from her treatment and stopped her medications several months ago. Now she is here with blurry vision and "floaters" in her eyes. What is the next step in the management of this patient?

(A) CD4 count and viral load
(B) Restart the antiretroviral treatment
(C) Start trimethoprim/sulfamethoxazole
(D) Funduscopy
(E) Prednisone

Answer:

(D) Funduscopy

Explanation:

This patient presents with blurring of vision of short duration. She discontinued taking antiretroviral medication for several months. Cytomegalovirus (CMV) retinitis has to be excluded. This is the most urgent step because if it is left untreated, permanent visual loss can occur in a matter of days. The diagnosis is made on clinical grounds and by funduscopy on a dilated ophthalmologic examination. Patients at risk for CMV retinitis are those with CD4 counts less than 100 cells/μL. The disease is characterized by rapidly progressive, painless, and irreversible loss of vision. Treatment is with intravenous ganciclovir or foscarnet, followed by oral ganciclovir or valganciclovir. The most common adverse effect of ganciclovir is neutropenia, and the most common adverse effect of foscarnet is renal failure. An intravitreal implant of ganciclovir is often added to retard progression of the disease. The ocular implantation has virtually no systemic adverse effects. Treatment for CMV retinitis has to be continued until the CD4 count is brought above 100 cells/μL for more than 6 months by the use of antiretroviral medications. Although measuring the CD4 count and viral load and restarting the antiretroviral medications are also important, it is far more urgent to diagnose and treat CMV retinitis; thus, funduscopy takes precedence. Prednisone has no place in the management of CMV.

Record # 43

Question/Fact:

A 48-year-old woman presents to the emergency department with complaints of blurred vision and general weakness. On further questioning, she admits to episodes of sweating and palpitations for the last 4 months since she started dieting to lose weight. Her past medical history is unremarkable, and she doesn't take any medications. On physical examination, patient appears confused and disoriented. Her vital signs are remarkable for tachycardia. The remainder of the physical examination, including her blood pressure, is normal. A fingerstick reveals blood glucose of 40 mg/dL. Her symptoms rapidly improve after administration of glucose solution. During her hospital stay, her 72-hour fast test reveals: glucose 40 mg/dL (normal >40 mg/dL); insulin 6.5 μU/mL (normal <6 μU/mL); C-peptide 0.3 mmol/L (normal <0.2 mmol/L); and proinsulin 6 pmol/L (<5 pmo1/L). What diagnostic procedure is the most beneficial in terms of necessary treatment?

(A) CT scan
(B) Celiac-axis angiography
(C) Endoscopic ultrasonography
(D) Percutaneous transhepatic pancreatic vein catheterization
(E) MRI

Answer:

(C) Endoscopic ultrasonography

Explanation:

This patient has an insulinoma. Once a biochemical diagnosis of an insulinoma has been made, preoperative localization should be attempted. There is general agreement that computed tomography (CT), magnetic resonance imaging (MRI), and celiac-axis angiography are not sufficiently sensitive in localizing insulinomas preoperatively, owing to the small size of most of these tumors (averaging 1.5 cm in diameter). Endoscopic ultrasonography is correct because there is general agreement that endoscopic ultrasonography provides the highest success rate in localization (over 90% in recent surveys). Percutaneous transhepatic pancreatic vein catheterization is incorrect because percutaneous transhepatic vein catheterization with insulin assay can be useful when the insulinoma is not found at the initial surgery with about 70% reliability.

Record # 44

Question/Fact:

A 30-year-old, HIV-positive man comes to the hospital with fever and a cough for two days. The cough is productive of green sputum. He also has increased shortness of breath. His lung examination shows rales only at the right base. Current medications are zidovudine, nelfinavir, and lamivudine. One month ago, his CD4 count was 450/μL, with an undetectable viral load. His temperature is 102 F, with a heart rate of 100/min and a respiratory rate of 23/min. His oxygen saturation is 95% on room air. What would be appropriate empiric management?

(A) Send sputum for an acid-fast stain and start isoniazid, rifampin, ethambutol, and pyrazinamide
(B) Bronchoscopy
(C) Ceftriaxone and azithromycin
(D) Ceftazidime and gentamicin
(E) Trimethoprim/sulfamethoxazole

Answer:

(C) Ceftriaxone and azithromycin

Explanation:

This patient is HIV positive and presents with community-acquired pneumonia (CAP). Although he is HIV positive, the most common organism to give this presentation is still Streptococcus pneumoniae. This is because this patient has high CD4 cells and well-controlled HIV disease, making Pneumocystis extremely unlikely. In addition, he has a productive cough, acute symptoms over only 2 days, and rales in a particular focal area -- all consistent with a lobar pneumonia. Bronchoscopy is not routinely indicated for CAP and would be useful for Pneumocystis. Gentamicin is not a useful drug for lung infections in general. Tuberculosis would give a longer duration of symptoms, as well as weight loss. Empiric therapy for tuberculosis should only be used when the evidence for tuberculosis is extremely strong. Pneumococcal vaccination should be done as soon as a patient is found to be HIV positive, even when the CD4 count is high.

Record # 45

Question/Fact:

A 45-year-old woman with a history of rheumatoid arthritis comes to your office for an annual check up. She currently takes celecoxib and methotrexate for inflammation and has no major complaints, except for a mild, nonproductive cough. She underwent a right knee replacement in the past. On physical examination, the patient is afebrile. There is symmetrical swelling of the knees, elbows, wrist, and metacarpophalangeal and interphalangeal joints. There are peripheral nodules of the elbow joints, as well as on the extensor surfaces of the extremities, and multiple joint deformities. The patient has a poor inspiratory effort, and the breath sounds are diminished over the right lung field. There is dullness to percussion up to the sixth intercostal space. The rest of the examination is unremarkable. The chest film demonstrates discrete nodules in both right and left lower lung fields, as well as fluid confined to the right lung field. What would be characteristic of the pleural effusion in this case?

(A) Low glucose, high LDH, low complement
(B) Pleural glucose is equal to serum glucose, normal pH, low complement
(C) Low glucose, low pH, high lymphocytic count, normal complement
(D) Increased numbers of neutrophils, low pH, high LDH, high protein
(E) Milky fluid, normal pH, normal protein, normal LDH

Answer:

(A) Low glucose, high LDH, low complement

Explanation:

The patient in this question has rheumatoid arthritis with lung involvement. The lung examination and chest film show fibrotic nodules and interstitial lung disease, causing her cough to be nonproductive. The question asks to identify the typical analysis of the fluid from rheumatoid lung disease. Choice A represents the fluid analysis from rheumatoid lung involvement. Rheumatoid arthritis typically has very low glucose and complement levels. Choice B represents fluid from lupus pleuritis. Choice C describes the fluid analysis of a patient with tuberculosis, which is characterized by an elevated number of lymphocytes. Acid-fast stain of the fluid or a pleural biopsy would confirm the diagnosis. Choice D represents an infectious (bacterial) process with numerous neutrophils detected in the fluid. Choice E represents fluid of a chylothorax from lymphoma involving the lung. The milky fluid is characteristic of a neoplastic mass pressing on the thoracic duct. The diagnosis of chylothorax is confirmed by finding an elevated level of triglycerides in the fluid with normal LDH and protein levels.

Record # 46

Question/Fact:

A 40-year-old woman is brought to the emergency department with complaints of severe weakness, back pain, and anorexia for the past three days. She has a history of a well-controlled connective tissue disease. Physical examination is remarkable for dry oral mucosa and decreased muscular strength, symmetrically. She has a history of coronary artery disease and does not know which medications she takes. The following lab values are obtained:

White cell count 14,000/mm3; hematocrit 36%; sodium 134 mEq/L; potassium 3.0 mEq/L; chloride mEq/L 118; bicarbonate 15 mEq/L; BUN 42 mg/dL; creatinine 1.9 mg/dL; glucose 100 mg/dL.

Arterial blood gas on room air -- pH 7.30; PCO2 29 mm/Hg; HCO3- 12 mm Hg; PO2 70 mm Hg.

Urinalysis -- specific gravity 1.030; pH 6.5; protein 1+; red cells 10-20/hpf.

Which of the following would be the most appropriate test?

(A) Urine electrolytes
(B) Spiral CT scan of abdomen
(C) Urine osmolarity
(D) Serum osmolarity
(E) Fludrocortisone stimulation test

Answer:

(C) Urine osmolarity

Explanation:

This patient has type I (classic distal) renal tubular acidosis (RTA). The presence of a normal anion gap, metabolic acidosis with hypokalemia, and elevated urinary pH suggests this etiology. Although urine electrolytes could be used to calculate a urinary anion gap, an elevated gap would not distinguish between the types of RTA. Also, a normal gap would be helpful to distinguish gastrointestinal bicarbonate loss from RTA types I, II, and IV. Type I RTA has an alkaline urinary pH, which is not seen in any of the other conditions. A spiral CT scan may be helpful to evaluate for nephrolithiasis and nephrocalcinosis in this patient. In general, patients with type I RTA often have associated hypercalciuria, nephrocalcinosis, and stone formation because of the high urinary pH. A fludrocortisone stimulation test would be helpful in type IV RTA.

Record # 47

Question/Fact:

A 55-year-old man comes to the office with a low-grade fever, malaise, weakness, and leg pain. His symptoms started three months ago. He took ibuprofen and acetaminophen without improvement. He denies cough or shortness of breath. His physical examination is remarkable for a few nodules on his lower extremities. They are about a centimeter in diameter and are raised and reddish purple. His hematocrit is 31% with a white cell count of 11,000/mm3. The BUN is 34 mg/dL, with a creatinine of 2.9 mg/dL and an ESR of 90 mm/h. The chest x-ray is normal. A 24-hour urine collection has 3.4 grams of protein. The renal biopsy shows severe, focal, necrotizing, glomerulonephritis with crescent formation. Which of the following is the most effective therapy for this patient?

(A) No treatment will help
(B) Cyclosporine
(C) Prednisone
(D) Cyclophosphamide and prednisone
(E) Methotrexate
(F) Etanercept

Answer:

(D) Cyclophosphamide and prednisone

Explanation:

This patient has polyarteritis nodosa (PAN). The diagnosis can be confirmed by biopsy of the organs that are most severely affected. The kidney biopsy typically shows focal necrotizing glomerulonephritis with crescent formation similar to what is observed in Wegener's granulomatosis. The P-ANCA test is sometimes positive, but it is not that helpful because it can be found in other conditions and is present only 20% of the time in PAN. The most effective therapy is a combination of prednisone and cyclophosphamide. These drugs in combination will not only control symptoms but will decrease mortality as well. They can bring the 5-year survival up from 20 to 90%. This is particularly true of those patients who have severe renal disease. Cyclosporine, methotrexate, and etanercept have no clear utility in the management of PAN. Prednisone alone will control some symptoms and the fever, but it will not decrease mortality or markedly diminish the long-term progression of the disease.

Record # 48

Question/Fact:

What is the appropriate mode of colorectal cancer screening for the following case?

A 33-year-old man who had a father die of colon cancer at age 44, a brother who died of colon cancer at age 51, and a grandfather who had colon cancer at age 77.

(A) Colonoscopy now and every 10 years
(B) Flexible sigmoidoscopy now and every 5 years
(C) Colonoscopy at age 50 and every 10 years
(D) Colonoscopy now and every 10 years
(E) Stool occult cards every year; colonoscopy if positive
(F) Colonoscopy at age 40 and every 5 years
(G) Colonoscopy in 3 years
(H) Colonoscopy in 1 year
(I) Colonoscopy every 1 to 2 years

Answer:

(I) Colonoscopy every 1 to 2 years

Explanation:

Colonoscopy is the preferred method of screening for colon cancer. Average-risk persons should undergo colonoscopy at age 50, and if normal, every 10 years. If a polyp is found, the colonoscopy should be repeated after 3 years. When there is a family history of colon cancer, screening should begin at age 40 or ten years prior to the age of the family member. The earlier date is respected. Follow-up examinations for persons with family histories of colon cancer should occur at 5-year intervals. When there are multiple family members, screening colonoscopy should be performed at age 25 and every 1 to 2 years (characteristic of persons with hereditary nonpolyposis colorectal cancer (Lynch syndrome). Colonoscopy is recommended 1 year after a hemicolectomy for colon cancer to verify the absence of recurrence and the presence of new lesions.

Record # 49

Question/Fact:

A 38-year-old alcoholic man with no symptoms is found to have an irregular pulse rate. There is no significant past medical history. Physical examination reveals cardiomegaly. His blood pressure is 100/64 mm Hg, pulse is 162/min, and respirations are 18/min. An EKG shows wide complex regular tachycardia and a QRS with a width of 0.14 seconds. Echocardiogram shows left ventricular dilation and moderate-to-severe dysfunction. What would be the best approach to management of this arrhythmia?

(A) Verapamil
(B) Procainamide
(C) Adenosine
(D) Digoxin
(E) Amiodarone

Answer:

(E) Amiodarone

Explanation:

This patient has dilated cardiomyopathy (probably from alcohol), causing ventricular tachycardia (VT). A wide complex tachycardia in a stable, asymptomatic patient can also be due to supraventricular tachycardia (SVT) with aberrancy. Verapamil is an incorrect answer because giving a calcium-channel blocker is dangerous and can lead to cardiovascular collapse in patients with VT. Procainamide is an incorrect answer because it has negative inotropic effects and should be avoided in patients with impaired left ventricular function. Adenosine is incorrect because adenosine is ineffective for VT. It blocks the AV node but not the accessory pathways. Digoxin is not effective for wide complex tachycardias that originate distal to the AV node. Amiodarone is effective for both SVT and VT. Amiodarone is the most effective drug to be used acutely in a hemodynamically stable VT. It is especially effective when there is diminished LV function.

Record # 50

Question/Fact:

A 21-year-old college student presents to the clinic with a lesion on the glans penis that was originally painless for few days but is now tender. On physical examination, the lesion is pustular with ulceration and surrounding erythema. Which of the following is NOT a common cause of the genital lesion in this patient?

(A) Haemophilus ducreyi
(B) Calymmatobacterium granulomatis
(C) Neisseria gonorrhea
(D) Treponema pallidum
(E) Herpes simplex

Answer:

(C) Neisseria gonorrhea

Explanation:

Of the answer choices listed, all are common causes of genital ulcers, except Neisseria gonorrhea. N. gonorrhea is a gram-negative intracellular diplococcus. It is associated with cervicitis, epididymitis, prostatitis, urethritis, and proctitis. Neisseria do not cause genital ulcer disease. Chancroid is a painful, soft ulcerative lesion with a necrotic base. Swabs from lesions should be cultured and will yield Haemophilus ducreyi as the causative organism. Treatment for chancroid is with a single dose of azithromycin. Calymmatobacterium (Donovania) granulomatis causes painless, infiltrated nodules that can slough, resulting in a shallow, sharply demarcated ulcer with a beefy red, friable base known as granuloma inguinale. The diagnosis of granulomas inguinale is made by biopsy, touch Prep, or smear of the lesion. Treatment is with doxycycline or trimethoprim/sulfamethoxazole, but it can also still be effectively treated with azithromycin. Treponema pallidum causes a painless ulcer (chancre), which starts as an erosion and develops into a painless, superficial ulcer with a clean base and firm, indurated margins. Herpes simplex virus causes multiple, painful, vesicular lesions, which form moist ulcers.

Record # 51

Question/Fact:

A 45-year-old woman comes to the emergency department with a complex elbow fracture after she slipped and fell on the street. She also mentions attacks of severe frontal headaches, sweating, and palpitations for the past month. Periodically, she experiences diffuse abdominal pain and mild shortness of breath. During these attacks, her blood pressure becomes elevated, sometimes up to 240/130 mm Hg. The baseline blood pressure is 150/100 mm Hg. Four months ago, she presented with similar complaints, and, after the diagnosis of pheochromocytoma was established, the tumor was successfully resected. Her blood pressure currently is 180/100 mm Hg. The right arm is immobilized in a sling. There is a 2/6 systolic ejection murmur best heard on the apex. The abdomen is normal. The orthopedic surgery consultant recommends immediate surgical repair of the elbow fracture. What is the necessary step prior to the operation?

(A) Complete workup for metastatic pheochromocytoma
(B) Chromogranin A level
(C) 24-hour urine collection for catecholamine levels
(D) Phenoxybenzamine to maintain a blood pressure below 160/90 mm Hg
(E) A whole body 123I MIBG scan

Answer:

(D) Phenoxybenzamine to maintain a blood pressure below 160/90 mm Hg

Explanation:

In 10% of patients, pheochromocytoma has metastasized by the time of the initial diagnosis. Ten percent also have involvement of both adrenal glands. It is essential to recheck urinary catecholamine levels 1 to 2 weeks after tumor resection and then to check the blood pressure regularly. If the patient requires an invasive diagnostic procedure or surgery, an adequate alpha blockade with phenoxybenzamine is absolutely necessary. Chromogranin A levels are elevated in patients with pheochromocytoma 83% of the time. There is no point in doing this test because it seems to already be established that a pheochromocytoma is present. All the answers, except the phenoxybenzamine, are diagnostic tests, not treatments. Because surgery is necessary for the elbow anyway, control of the blood pressure is more important than precise anatomic localization. MIBG testing is extremely specific (98% accurate) in localizing the anatomic position of metastatic disease. It would not change the need to control the blood pressure with phenoxybenzamine prior to the surgery.

Record # 52

Question/Fact:

A 64-year-old man is brought to the hospital with complaints of intolerable headache and blurry vision in the right eye for the past two hours. His medical history is significant for hypertension, diabetes mellitus, and bronchial asthma. In the past he was intubated twice during hospitalization for asthma exacerbations. He has asthma attacks at least once a day and frequently wakes up at night with shortness of breath. His medications include furosemide, enalapril, salmeterol, Atrovent, and steroid inhalers. For the past year, he started using fluticasone (Flovent) up to six times a day. Four months ago, his Flovent 110 inhaler was changed to Flovent 220. He is agitated and screaming. His temperature is 99.8 F, blood pressure is 190/100 mm Hg, heart rate is 104/min, and his respiratory rate is 22/min. The pain is focused in the right frontal area and right eye. The periorbital area on the right is hyperemic and edematous. The right pupil is mid-dilated and nonreactive to light. His eye movements are normal. There is photophobia on the right side. Meningeal signs and focal neurological deficits are absent. He is moderately short of breath and has wheezes on lung auscultation bilaterally. What will be most important for the long-term management of this patient's new medical problem?

(A) Pilocarpine eye drops for a long term
(B) Discontinuation of high-dose inhaled glucocorticoids
(C) Instruct to use salmeterol strictly twice a day
(D) Imaging studies of cavernous sinuses
(E) Lumbar puncture

Answer:

(B) Discontinuation of high-dose inhaled glucocorticoids

Explanation:

This patient presents with an acute glaucoma attack precipitated by the administration of high doses of inhaled glucocorticoids. High-dose inhaled glucocorticoids may produce better asthma control for patients with moderate to severe persistent asthma. They include fluticasone (Flovent 44, Flovent 110, and Flovent 220). At the dose of 1,000 to 1,500 mg/day or more, they may lead to systemic absorption sufficient enough to cause adverse effects, such as ecchymoses, cataracts, elevated intraocular pressure, loss of bone mass, and suppression of the hypothalamic-pituitary-adrenal axis. Among patients older than 65 years, use of 1,500 mg a day of inhaled corticosteroids for at least three months leads to a 40% increased risk of elevated intraocular pressure or open-angle glaucoma. This risk is still less than that associated with the use of oral glucocorticoids. For this patient, the most important step in the long-term management of glaucoma in the future will be discontinuation of high-dose inhaled glucocorticoids. Pilocarpine and other eye drops will be ineffective if the patient continues using Flovent 220. Thrombosis of cavernous sinus is unlikely in the absence of gaze palsies. Salmeterol is a β2-selective-adrenergic agonist, which should be used with caution in cases of glaucoma. It is associated with a smaller risk of increased intraocular pressure compared with high-dose inhaled glucocorticoids.

Record # 53

Question/Fact:

A 50-year-old man has been experiencing pain of his wrists, knees, and ankles, accompanied by a low-grade fever for three weeks. He also has exertional dyspnea that limits his performance at work as a physical trainer in a prison. He denies chest pain, cough, or hemoptysis. He has otherwise been healthy, except for previous exposure to tuberculosis for which he is taking isoniazid and pyridoxine. He has no allergies. He has not consumed any alcohol since he started his new medications two months ago. Physical examination is remarkable for a temperature of 100.4 F. The antinuclear antibody is positive, and the ESR is elevated. What serological results would you expect to find in this patient?

(A) Rheumatoid factor and anti-Jo 1
(B) Low complement levels and antibodies to double-stranded DNA
(C) Rheumatoid factor and low complement levels
(D) Antihistone antibody and normal complement levels

Answer:

(D) Antihistone antibody and normal complement levels

Explanation:

Drug-induced lupus from the isoniazid is the diagnosis for this patient. He had no evidence of lupus prior to this last month. Other drugs associated with drug-induced lupus include chlorpromazine, methyldopa, hydralazine, procainamide, and possibly Dilantin, penicillamine, and quinidine. This patient presents with arthritis, fever, and serositis, which are the most commonly reported clinical features of lupus. CNS and renal involvement are uncommon in drug-induced lupus. Drug-induced lupus is rarely associated with a positive antibody test to double-stranded DNA, and the complement level is usually normal. Antihistone antibodies are present in 95% of patients with drug-induced lupus.

Record # 54

Question/Fact:

A 53-year-old woman is brought to her physician's office for worsening shortness of breath. She normally walks 2 miles up and down hills in her neighborhood with her dog, but over the last several months, she has been unable to walk to the end of the street without stopping to catch her breath. She has a history of hypertension, diabetes, and depression. She takes medications for blood pressure, diabetes, and unknown medications for weight loss. Her husband claims that she gets all the medications from Tijuana, Mexico, because they're cheaper there.

She is an obese female with abdominal and thigh stretch markings. She is afebrile. Vital signs are: blood pressure 95/70 mm Hg, respirations 18/min, and pulse 110/min. There are decreased breath sounds bilaterally. Examination of the heart shows that S1and S2 are clearly audible with a systolic murmur at the apex radiating to the left axilla.

In two weeks, you learn that this patient committed suicide. An autopsy shows abnormal vascular findings in the lungs consistent with high pulmonary pressure, and the mitral valve shows irregular thickening and fibrosis. Several of the other valves are involved as well. There is also pulmonary artery thickening. Which of the following most likely caused her problem?

(A) Her obesity
(B) Congenital heart/lung disease
(C) Rheumatic heart disease
(D) Endocarditis
(E) Weight loss medication

Answer:

(E) Weight loss medication

Explanation:

This woman presents with signs of dyspnea, which has progressively gotten worse. The autopsy shows mitral valve destruction, along with glistening white leaflets, irregular thickening, and pulmonary hypertension. This is suggestive of endocardial fibrosis, not endocarditis. Besides that, she never had a fever or positive blood cultures. There is no specific mention of vegetations being found at autopsy. Her history shows obesity and that she buys medications in Mexico; this suggests that she was taking fenfluramine/phentermine (Fen/Phen). (This drug is no longer available legally in the United States.) These drugs were removed from the market in the United States because of valve disease and pulmonary hypertension. These medications, when used together, have been shown to cause pulmonary hypertension and cardiac fibrosis, leading to valvular disease.

Obesity can lead to left ventricular hypertrophy. Rheumatic heart disease usually gives mitral stenosis. Although she has irregular thickening of the mitral valve, mitral stenosis usually gives a diastolic murmur, not the systolic murmur found in this patient. It is unlikely that congenital heart disease will make its first appearance at the age of 53.

Record # 55

Question/Fact:

A 36-year-old woman is seen in the emergency department for palpitations and exercise intolerance. She is mildly short of breath but denies chest pain. Her symptoms began two hours prior to arrival. She states that she has had similar episodes in the past but has never been diagnosed. There is no other significant past medical history, and her social history is unremarkable. Her vital signs are normal. An EKG at that time was also normal. She is started on oxygen by nasal canula at 2 liters per minute and was admitted for observation due to her shortness of breath. Later that evening, she complains of worsening palpitations, and an EKG reveals atrial fibrillation. Her vital signs are: blood pressure 110/68 mm Hg, pulse 138/min, respirations 20/min, and temperature 98.4 F. What is the most appropriate medication at this time?

(A) Adenosine 6 mg IV push
(B) Procainamide infusion of 20 mg/min
(C) Amiodarone
(D) Diltiazem intravenously
(E) Digoxin orally
(F) Transesophageal echocardiogram

Answer:

(D) Diltiazem intravenously

Explanation:

The most important initial step in this patient is to control the heart rate. Diltiazem will lower the hear rate rapidly, as will intravenous beta-blockers, such as metoprolol. Adenosine is effective for supraventricular tachycardia but is not effective for atrial fibrillation. Procainamide is useful to convert atrial arrhythmias to sinus rhythm but would not be useful until the rate has been controlled with an agent that blocks down the AV node. Digoxin can also be used to control the rate but even intravenously does not work as rapidly as verapamil, diltiazem, or beta-blockers. Oral digoxin would be far too slow. Amiodarone is very good at maintaining a patient in sinus rhythm after being converted by medications or electrical cardioversion. Although an echocardiogram would be useful in determining the etiology of the rhythm disturbance and if there is a thrombus present, it would not be as acutely important as slowing the heart rate. Even if there were a thrombus, you still would need to slow the rate.

Record # 56

Question/Fact:

A 28-year-old woman comes to the emergency department with right upper quadrant and lower, aching, abdominal pain over the past three to four days. She also complains of fever, chills, generalized weakness, and malaise. The patient has a poor appetite and has vomited several times. The patient has not noticed a vaginal discharge and has normal bowel movements. Her last menstrual period was about four weeks ago, and her cycles are generally regular. The patient currently has a temperature of 101.2 F. Abdominal examination reveals right upper quadrant tenderness. She also has bilateral adnexal tenderness, and a yellow discharge is coming from the cervical os. Her white blood cell count is 13,000/mm3, AST is 40 U/L, ALT is 32 U/L, alkaline phosphatase is 88 U/L, and the erythrocyte sedimentation rate is 95 mm/h. What is the most likely diagnosis?

(A) Ascending cholangitis
(B) Acute cholecystitis
(C) Fitz-Hugh-Curtis syndrome
(D) Ectopic pregnancy
(E) Tubo-ovarian abscess

Answer:

(C) Fitz-Hugh-Curtis syndrome

Explanation:

This patient presents with lower abdominal pain, bilateral adnexal tenderness, fever, and a cervical discharge, which are all consistent with pelvic inflammatory disease (PID) or salpingitis. This case is different because of the right upper quadrant abdominal pain and tenderness, which in this case represents perihepatitis from the organisms of PID. This perihepatitis is also known as Fitz-Hugh-Curtis syndrome (FHC). Symptoms of FHC syndrome, which include pleuritic right upper abdominal pain, can develop in 3 to 10% of women with acute PID. The onset of symptoms occurs during or after the onset of symptoms of PID and may predominate over the lower abdominal symptoms, often leading to a misdiagnosis of cholecystitis. FHC syndrome is caused by the same gonococcal and chlamydial organisms that cause PID. Because the inflammation is generally limited to the liver capsule, it spares the parenchyma. In this case, the transaminases and ultrasound are generally normal. Ascending cholangitis is unlikely in the absence of jaundice. Although acute cholecystitis could account for the right upper quadrant pain and tenderness, it could not account for the pelvic examination abnormalities and the discharge from the cervical os. Tubo-ovarian abscess would give isolated unilateral adnexal tenderness with a unilateral mass. It can be difficult to distinguish between an ectopic pregnancy and an ovarian abscess or cyst. Ultrasound and a pregnancy test are often necessary to distinguish between them.

Record # 57

Question/Fact:

A 66-year-old man presents to the emergency room complaining of discoloration of the toes and fingers of one week's duration. He also has had "angina-like" chest pain for the past two days. His past medical history is significant for recently diagnosed non-Hodgkin's lymphoma. He is currently on combination chemotherapy. He denies smoking and alcohol use.

He is afebrile with a blood pressure of 120/70 mm Hg and a pulse of 70/min. Cardiac examination shows a faint, holosystolic murmur, and the lungs are clear. The fingertips and toes appear necrotic. The neurologic exam is intact. The initial EKG reveals ST elevation in leads V2-V5. The complete blood count (CBC) and prothrombin (PT)/partial thromboplastin time (PTT) are normal. Troponins are elevated.

The patient soon develops an acute mental status change in the emergency department with aphasia and right-sided weakness. The CT scan of the head reveals an acute ischemic stroke with no evidence of hemorrhage.

Which is the first test to perform in diagnosing this patient?

(A) Protein C and S assays
(B) Homocysteine level
(C) Transesophageal echocardiogram
(D) Chest CT scan
(E) Antiphospholipid antibodies

Answer:

(C) Transesophageal echocardiogram

Explanation:

The patient seems to be having episodes of emboli to the arterial structure of the body. The necrotic fingers and toes can be caused from small emboli to the distal peripheral and digital arteries. This could also account for emboli to the coronary arteries, resulting in a myocardial infarction in a patient with no risks for coronary disease beyond his age. The same reasoning would be true of what seems to certainly be an acute embolic stroke. The most effective chemotherapy for non-Hodgkin's lymphoma is still "CHOP," in which the "H" represents hydroxyadriamycin. Adriamycin may lead to cardiac toxicity, which may be predisposing to these emboli.

Protein C and S deficiency lead to the gradual onset of venous thrombosis, not the acute arterial disease described here. Homocysteine abnormalities are a risk for thrombosis, but it should never give this dramatic of a presentation. They often present with the more gradual onset of a thrombosis in development. Antiphospholipid antibodies can give arterial clots, but the PTT should be elevated. Even if this is a suspicion, you cannot leap to this diagnosis without doing the transesophageal echo first to exclude an obvious source of emboli.

Record # 58

Question/Fact:

A 45-year-old man presents with the sudden onset of nausea, vomiting, and chest discomfort, which started three hours ago. The patient took Maalox and Tums, but they didn't relieve his symptoms. His past medical history is significant for gastroesophageal reflux disease.

Vital signs: temperature 100.9 F (rectal), heart rate 40/min, blood pressure 86/52 mm Hg, and respiratory rate 26/min. Physical examination is significant for jugular venous distension with clear lungs. EKG shows ST elevation in II, III, and AVF, and the chest x-ray is normal. Oxygen saturation is 98% on room air. Which of the following would be the most appropriate initial therapy?

(A) Aspirin, nitroglycerin, morphine, ACE inhibitors
(B) Transcutaneous pacemaker
(C) Thrombolytics
(D) Atropine sulfate
(E) Metoprolol

Answer:

(D) Atropine sulfate

Explanation:

The combination of low blood pressure and bradycardia suggests a vagal response, so an anticholinergic agent, such as atropine, is the correct answer. Volume replacement is required, especially if hypotension persists after correction of the bradyarrythmia. Nitroglycerin, ACE inhibitors, and beta-blockers are contraindicated in this setting because of low blood pressure. Although thrombolytics should be given as soon as possible, they are not as urgent as using atropine to correct the heart rate. Beta-blockers are absolutely contraindicated in the presence of bradycardia with hemodynamic instability. A transcutaneous pacemaker should definitely be applied, but this question is asking you to determine the appropriate order of therapy. Atropine can be given more rapidly and may correct the problem in the short term. Also, atropine is certainly more comfortable than using the transcutaneous pacemaker with the amperage turned up high enough to capture the heart. In this patient, the heart rate must be fixed (thus raising the blood pressure) while you are getting the pacemaker hooked up. As soon as the blood pressure is fixed, thrombolytics can be given or angioplasty can be performed.

Record # 59

Question/Fact:

A 35-year-old man with history of intravenous drug use and HIV was admitted to the hospital because of abnormal blood test results discovered during his regular follow-up visit to the methadone clinic. His medications include zidovudine, lamivudine, and nelfinavir, which he takes on 4 to 5 days of the week. He has a strong family history of diabetes mellitus and hypertension.

Physical examination shows a cachectic man who is agitated and confused. He is afebrile, with a pulse rate of 110/min, a respiratory rate of 26/min, and a blood pressure of 140/90 mm Hg. The skin turgor is diminished. Bilateral supraclavicular and inguinal lymphadenopathy are present. The chest is clear, and heart sounds are normal. Abdominal exam shows no hepatosplenomegaly. There is 3+ pedal edema. Laboratory studies reveal:

WBC 15,500/mm3, hematocrit 35.1%, platelets 233,000/mm3, BUN 42 mg/dL, creatinine 3.5 mg/dL, albumin 2.2 g/dL, Na 141 mEq/L, K 5.0 mEq/L, Cl 110 mEq/L, CPK 20 U/L, serum complement level normal.

Urinalysis shows: pH 5.9, specific gravity 1.015, protein 2+, hemoglobin dipstick trace positive with 10 to 15 erythrocytes/hpf. Urine toxicology screen is positive for cocaine and opioids.

In this patient, what condition is most consistent with these laboratory findings and clinical picture?

(A) Cocaine-associated rhabdomyolysis
(B) Dehydration
(C) Medication-induced nephrotoxicity
(D) HIV nephropathy
(E) Acute interstitial nephritis

Answer:

(D) HIV nephropathy

Explanation:

The patient most likely has HIV-associated nephropathy. This disorder presents as nephrotic syndrome with normal complement levels. These patients also may have more nephritic symptoms than membranous nephropathy and minimal change disease. The diagnosis is supported by renal biopsy. Light microscopy shows the lesions of focal segmental glomerular sclerosis. Immunoglobulin M (IgM) and C3 are seen in the sclerotic lesions on immunofluorescence. Most patients present with microscopic hematuria and significant proteinuria. The only treatment is to control the HIV disease. The family history of diabetes and hypertension is irrelevant because this patient does not have these diseases. Taking HIV medications only 70% of the time, as this patient does, will not control his HIV disease, and that is why he can have HIV-associated renal disease.

In rhabdomyolysis from cocaine, there are brown, pigmented casts and myoglobin on urinalysis. The urinalysis should also be prominently positive for blood, with no red cells seen on the microscopic examination. In this case, the CPK is normal, and there is only a trace amount of blood on the urinalysis.

Acute interstitial nephritis is associated with hematuria and pyuria, which is mostly made up of eosinophils. Prerenal azotemia from dehydration would have a BUN:creatinine ratio of >15:1, and the only finding on urinalysis would be hyaline casts, not protein or red and white cells. Adefovir and cidofovir can produce proximal renal tubular dysfunction, which is associated with polyuria and proteinuria. The only protease inhibitor that is associated with renal dysfunction is indinavir, not nelfinavir. Lamivudine and zidovudine are not associated with renal failure.

Record # 60

Question/Fact:

A 35-year-old woman is brought to the emergency department after she was found wandering the streets. On the way to the hospital, she develops an episode of generalized seizures. She has a history of a recent admission for depression with suicidal ideation. On arrival to the hospital, she develops vomiting with "coffee grounds" gastric material. Her temperature is 101.4 F, heart rate is 110/min, and respiratory rate is 30/min. The patient is confused and agitated, complaining of ringing in her ears. Her skin is dry and pale. The breathing is deep and rapid. Her heart is normal, and lung auscultation reveals bibasilar crackles. The abdomen is mildly distended but not tender to palpation. Her neurological exam reveals confusion without focal symptoms.

Laboratory studies show: sodium 148 mEq/L, potassium 5.1 mEq/L, chloride 98 mEq/L, serum bicarbonate 15 mEq/L, BUN 29 mg/dL, creatinine 1.9 mg/dL, and glucose 100 mg/dL. Her blood gas shows: pH 7.35, pCO2 26 mm Hg, and pO2 96 mm Hg, with a 97% oxygen saturation. Her prothrombin time is 24 seconds. An EKG is normal besides tachycardia. After administration of activated charcoal, what is the next step in the management of this patient?

(A) Esophagogastroduodenoscopy
(B) Hemodialysis
(C) Sodium bicarbonate
(D) Phenytoin
(E) Bromocriptine
(F) Thiamine

Answer:

(C) Sodium bicarbonate

Explanation:

This patient presents with salicylate overdose. The key to the diagnosis in this case is the history of a recently suicidal patient with hyperventilation and tinnitus combined with evidence of renal toxicity and a metabolic acidosis with an elevated anion gap. A single ingestion of more than 200 mg/kg is likely to produce significant intoxication. Poisoning may also occur as a result of chronic excessive dosing over several days. The half-life in small doses is only 2 to 3 hours, but it may increase to 20 hours in cases of intoxication. Salicylates uncouple cellular oxidative phosphorylation, resulting in anaerobic metabolism and excessive production of lactic acid and heat. They also interfere with several Krebs' cycle enzymes. Acute ingestion causes nausea and vomiting and occasional gastritis. Moderate intoxication causes hyperpnea, tachycardia, tinnitus, and an elevated anion-gap metabolic acidosis. Serious intoxication presents with seizures, confusion, coma, pulmonary edema, and hyperthermia. The prothrombin is often elevated. The diagnosis is confirmed by measuring the serum salicylate level. The first step is to empty the stomach by gastric lavage if the patient presents immediately after ingestion and to administer activated charcoal. Metabolic acidosis should be treated with sodium bicarbonate, which is crucial because acidosis promotes a greater entry of salicylates into cells and worsens the toxicity. Bicarbonate also increases the urinary excretion of the aspirin. Hemodialysis may be lifesaving and is indicated in patients with severely altered mental status or highly elevated salicylate levels. Bicarbonate should be tried first. This patient most likely has erosive gastritis, and endoscopy should be performed later after detoxification is completed. Bromocriptine is used for the treatment of neuroleptic overdose.

Record # 61

Question/Fact:

A 40-year-old man comes to the clinic for a routine visit. He has a past medical history of type 1 diabetes mellitus since the age of ten and hypertension. His medications include insulin injections and quinapril. He currently feels well. On physical examination, his pulse is 86/min, and his blood pressure is 145/90 mm Hg. Edema is present. Laboratory evaluation discloses the following: Sodium 136 mEq/L; potassium 5.9 mEq/L; serum bicarbonate 18 mEq/L; creatinine 2.1 mg/dL; chloride 112 mEq/L; fasting plasma glucose 120 mg/dL. Urinalysis shows a 2+ proteinuria. This has remained unchanged over the last six months. On the basis of these findings, what should the physician recommend?

(A) Urine free cortisol and plasma ACTH
(B) Stop quinapril and start an angiotensin-receptor blocker
(C) Random serum cortisol
(D) Administration of hydrocortisone and furosemide
(E) Stop quinapril, order a cosyntropin-stimulation test, and start furosemide
(F) Give kayexcelate, start furosemide, restrict dietary potassium, and continue quinapril

Answer:

(F) Give kayexcelate, start furosemide, restrict dietary potassium, and continue quinapril

Explanation:

The point of this question is to recognize that although a mild hyperkalemia is worrisome, stopping ACE inhibitors in a diabetic with proteinuria, and risk having the patient end up on dialysis, is even more worrisome. The priority in this situation is to manage the high potassium and continue the ACE inhibitor. Kayexcelate will acutely lower the potassium level. Restricting dietary potassium and using furosemide will help control it on a long-term basis.

Hyporeninemic hypoaldosteronism occurs most commonly in adults with diabetes mellitus and is associated with renal failure, hyperkalemia, and metabolic acidosis. The sequence of events is first the retention of sodium and water, leading to hypervolemia and intravascular hypertension. This leads to logically appropriate low renin and aldosterone levels. Hypoadrenalism can mimic many aspects of type IV renal tubular acidosis (RTA). The test for making a diagnosis of hypoadrenalism is a cosyntropin-stimulation test. The diagnosis of adrenal insufficiency is excluded by noting an adequate increase in serum cortisol with the cosyntropin (ACTH) stimulation test. A normal sodium level, edema, hypertension, and proteinuria are not found in Addison's disease. The cosyntropin stimulation test is not necessary, given the clear history of diabetes as an obvious cause of type IV RTA.

Several classes of drugs suppress aldosterone, such as ACE inhibitors, NSAIDs, and chronic heparin use. A random serum cortisol should not be measured because there is substantial overlap with normal values due to the pulsality and diurnal variation of this hormone's secretion. The morning serum cortisol is useful if the level is very low or very high. For intermediate values, follow-up tests must be performed.

Urine-free cortisol and plasma ACTH are not useful for making the diagnosis of adrenal insufficiency because they are normal in many cases of adrenal insufficiency. Furosemide can be used alone in a hypertensive patient with type IV renal tubular acidosis. Furosemide will treat both the hyperkalemia and the acidosis. Oral bicarbonate is sometimes added. In a diabetic patient with renal disease, an ACE inhibitor should virtually always be included in the treatment regimen, as they have been clearly shown to significantly reduce the progression of diabetic nephropathy.

Record # 62

Question/Fact:

A 55-year-old mechanic comes to the emergency department with the sudden onset of pain and swelling in his right knee that started several hours ago. He denies trauma to the knee. He had two similar episodes of knee pain in the past, which subsided without treatment. He has hypertension and takes a diuretic, the dose of which was increased recently. He has a temperature of 102 F. The right knee joint is edematous, warm, and tender, with a limited range of motion. An x-ray shows no fracture. The serum uric acid result is normal. The synovial fluid is normal on Gram stain with a leukocyte count of 57,000/mm3, which is 80% neutrophils. Negatively birefringent crystals are seen on light microscopy. What is the most appropriate first line of treatment in this patient?

(A) Antibiotics
(B) Intra-articular steroids
(C) Oral prednisone
(D) Colchicine
(F) ACTH

Answer:

(D) Colchicine

Explanation:

This patient has acute inflammatory monoarthritis of the lower extremity with numerous white cells and negatively birefringent crystals in the joint fluid -- all consistent with gout. Thiazide diuretics inhibit the renal excretion of uric acid and may cause hyperuricemia. Giving colchicine as a first line of treatment in this patient would be both diagnostic and therapeutic. Patients take a pill every hour until the pain goes away or until they develop diarrhea. The adverse effects of colchicine are abdominal cramps, diarrhea, nausea, and vomiting. Although the patient has a fever and a hot, red, tender, swollen joint, there are very clear negatively birefringent crystals in the joint fluid. Therefore, antibiotics are not needed. Steroids and ACTH would only be used in patients who do not respond to either oral NSAIDs or colchicine. If the patient has monoarticular arthritis and does not respond to colchicine or NSAIDs, then intra-articular steroids would be indicated. Polyarticular involvement needs systemic therapy. Allopurinol has no place in the management of acute attacks. It is only given in between attacks as preventative therapy. ACTH has been used in those with disease refractory to therapy. NSAIDs were not offered as an answer choice in this question. If they had been, then NSAIDs would be the answer. They have the same efficacy as colchicine with less gastrointestinal side effects.

Record # 63

Question/Fact:

A 79-year-old man is admitted to the emergency department because of a loss of consciousness for approximately four minutes after he fell. He had been walking home after spending the morning at the supermarket and then suddenly fell to the ground. The patient remembers regaining consciousness and woke to find himself facedown on sidewalk with abrasions on his nose and forehead. This is the patient's first syncopal event, and he is otherwise in good health. He recalls feeling lightheaded and shaky just before the fall and currently is experiencing nausea. His blood pressure is 84/68 mm Hg, pulse is regular at 165/min, and the respiratory rate is 23/min. There are no tongue abrasions, jugular venous distention, or focal neurological deficits. There are no murmurs. What is the next best step in the management of this patient?

(A) Vagal maneuvers and administering adenosine
(B) Lidocaine
(C) Asynchronized cardioversion
(D) Synchronized cardioversion
(E) Amiodarone

Answer:

(D) Synchronized cardioversion

Explanation:

This patient presents with syncope. Syncope is defined as a transient loss of consciousness and postural tone due to inadequate cerebral blood flow. The history of a sudden loss of consciousness in this patient with a resulting fall that causes abrasions to the face is consistent with cardiogenic syncope. The etiology of cardiogenic syncope can be from either mechanical obstruction to the flow of blood or from an arrhythmia. There are no murmurs evident on physical examination, making aortic stenosis or hypertrophic obstructive cardiomyopathy unlikely. Cardiac syncope is commonly due to disorders of automaticity, such as sick sinus syndrome; conduction disorders, such as atrioventricular block; and tachyarrythmias, as is the case in this patient.

Although no EKG results are given, the patient is presenting with symptomatic hypotension and a pulse of 165/min. Maximum heart rate is calculated as 220 minus the age. In a 79-year-old patient, it is virtually impossible to have a sinus rhythm at a rate >140/min. The rate of 165/min definitely has to be from an arrhythmia. No matter what the specific etiology is, synchronized cardioversion is the right therapy in a hypotensive patient. Although vagal maneuvers may treat supraventricular tachycardia (SVT), it is less likely to be the cause of a tachyarrhythmia that leads to a syncopal event. Besides that, you would still cardiovert the patient if he were hypotensive, not perform vagal maneuvers that can easily lower the blood pressure further.

Ventricular tachycardia is the arrhythmia that would most likely result in a loss of consciousness. The fact that this patient is symptomatic with a systolic blood pressure of <90 mm Hg is the reason you would cardiovert this patient with a synchronized cardioversion of 100 to 200 Joules (J). The cardioversion is synchronized if there is a rhythm present to synchronize to. All cardioversions are synchronized, except for ventricular fibrillation. If the patient had no symptoms and a systolic pressure of >90 mm Hg, you could use medical therapy. Lidocaine or amiodarone by intravenous bolus injection may terminate the arrhythmia. An echocardiogram would be the correct choice if a murmur of aortic stenosis, pulmonary stenosis, or hypertrophic cardiomyopathy was heard or if you suspected cardiac tamponade. An EKG is, of course, essential. The question tests your understanding of who needs cardioversion and who can be treated with medications. We are not implying that you would not do the EKG prior to delivering therapy.

Record # 64

Question/Fact:

A 31-year-old man presents to his physician for generalized weakness associated with an unsteady feeling while standing or walking. The patient also complains of a few episodes of double vision and dizziness lasting from several minutes to a few hours over the past six months. An MRI of the brain is done and shows multiple, bright, signal abnormalities in the white matter on T2-weighted images. Which of the following is true regarding this patient's condition?

(A) A CT scan with contrast will aid in making the final diagnosis
(B) The cerebrospinal fluid with elevated lymphocyte levels and low protein levels
(C) Plasmapheresis is consistently beneficial for routine care
(D) Chronic steroid therapy is indicated in this patient
(E) Interferon-beta will aid in long-term management

Answer:

(E) Interferon-beta will aid in long-term management

Explanation:

CT scanning of the head adds nothing to the diagnosis of multiple sclerosis when an MRI has already been done. It is a step backward from the MRI in terms of both sensitivity and specificity. Plasmapheresis has rarely shown a benefit in steroid-unresponsive cases. Plasmapheresis is far from being consistently beneficial in routine care. Plasmapheresis may be lifesaving, however, in the management of fulminant and acute cases of spinal or cerebral multiple sclerosis. Chronic steroid use should be avoided. High doses of steroids can be used for acute exacerbations. Disease-modifying therapy with interferon-beta or glatiramer is the preferred long-term management. The cerebrospinal fluid of those with multiple sclerosis typically has an elevated protein level with a low or normal white-cell count.

Record # 65

Question/Fact:

A 52-year-old smoker comes to your office. What is the best step in this patient?

(A) Annual analysis of myc gene amplification
(B) Annual chest x-ray
(C) Transdermal nicotine patches
(D) Beta-carotene supplementation
(E) Annual sputum cytology

Answer:

(C) Transdermal nicotine patches

Explanation:

Transdermal nicotine-replacement therapy has been shown to increase the quit rate of smoking when combined with counseling programs on tobacco cessation. This is a form of primary prevention. Annual chest x-rays, analysis of myc gene amplification, and screening for mutation in the ras gene are not cost-effective and do not lower lung-cancer death rates. Lung cancer incidence and mortality are increased by beta-carotene. Thus, beta-carotene is contraindicated in cigarette smokers. Sputum cytology has insufficient sensitivity to be an adequate screening test.

Record # 66

Question/Fact:

A 65-year-old woman comes to the emergency department complaining of back pain. The pain started two days prior to her visit and has been progressively worsening. She denies any fever or history of cancer. The physical examination is significant for point tenderness over the lower spine. The neurologic examination is negative. Serum chemistries obtained in the emergency department are as follows: calcium 8.7 mg/dL, phosphorus 3.2 mg/dL, and alkaline phosphatase 73 U/L. What is the most likely diagnosis?

(A) Osteoporosis
(B) Osteomalacia
(C) Paget's disease
(D) Multiple myeloma
(E) Metastatic bone disease

Answer:

(A) Osteoporosis

Explanation:

Any patient with metabolic bone disease and normal serum calcium, phosphorus, and alkaline phosphatase is most likely to have osteoporosis.

Record # 67

Question/Fact:

A 33-year-old man comes to your office to discuss discontinuing his antiepileptic medications. One year ago, he was treated for viral meningitis, which was complicated by several episodes of generalized tonic-clonic seizures. The last seizure episode happened a few days before his discharge from the hospital at that time. His current medications are phenytoin and carbamazepine. He has not had any further episodes of seizure activity over the past year. His father has a history of seizures since childhood, and his two-year old son had an episode of febrile seizures last year. His physical examination is unremarkable. The EEG is normal. What is your advice?

(A) Stop all medications
(B) Continue medications indefinitely
(C) Repeat the EEG after sleep deprivation for 24 hours
(D) Order a CT scan of the head
(E) PET scan of the brain

Answer:

(C) Repeat the EEG after sleep deprivation for 24 hours

Explanation:

When antiepileptic medications should be discontinued is always a controversial question. Many patients with epilepsy become seizure-free for extended periods of time. There have been numerous attempts to identify which patients can stop antiepileptic drugs without a high risk of relapse. Successful drug withdrawal is most likely if initial seizure control was achieved using monotherapy and there weren't that many episodes of seizures to begin with. Successful withdrawal of therapy is also more likely if the EEG and neurological examination are normal. In addition, the longer the seizure-free interval has been, the more likely it is you will be able to safely stop the drugs. In this question, the patient developed seizures secondary to a temporary condition provoked by viral meningitis. He has been seizure-free for only one year and required polytherapy to achieve adequate control. He also has a family history of a seizure disorder, so this patient requires extra caution when thinking about discontinuing his medications. In general, it is preferable to wait for a period of two years without seizures to plan on stopping medications. In addition, they should be stopped one at a time, not both at the same time. The fact that the EEG is normal is not very helpful because most EEGs obtained between seizures will be normal. The chance of capturing epileptiform abnormalities on an initial EEG is 40 to 50%. The chance of capturing epileptiform activity is enhanced by sleep deprivation for 24 hours before the test and by the patient's sleeping during a portion of the EEG recording. In a way, an EEG after sleep deprivation is like a stress test for the patient's brain. If this type of EEG is normal, then there is a higher likelihood that the medications can be stopped safely.

Record # 68

Question/Fact:

A 44-year-old woman comes to the clinic complaining of fatigue and depression for the past several months. Her symptoms began gradually and have worsened over the last several weeks. Physical examination is within normal limits, but she has not been menstruating for the last two years. Thyroid function tests show a thyroid-stimulating hormone (TSH) concentration of 3.8 mU/L (normal 0.4-4.2 mU/L) and free T4 of 0.3 ng/dL (normal 0.9-2.4 ng/dL). What is the next step in the management of this patient?

(A) Start levothyroxine
(B) Radioactive-iodine uptake
(C) Thyroid ultrasound
(D) MRI of the brain
(E) Check thyroglobulin antibody titers

Answer:

(D) MRI of the brain

Explanation:

In a patient with clinical manifestations of hypothyroidism, the response of a normal pituitary to a failing gland is to secrete thyroid-stimulating hormone (TSH). The "normal" TSH in the patient is actually abnormal because it is an inappropriate response to low levels of thyroid hormone in the blood. The level of TSH should be elevated if the free T4 is truly low. In addition, patients with pituitary disease produce a defective TSH, which has reduced biological activity. Another reason why the MRI is the correct answer is because it may identify a pituitary lesion responsible for the flaccid response of the pituitary to low levels of circulating thyroid hormone. The adrenal function needs to be tested prior to therapy with thyroxine because treatment may lead to a crisis of acute adrenal insufficiency. Thyroid hormone will lead to an increased metabolic state, which can consume the remaining amounts of cortisol and precipitate acute adrenal insufficiency.

Record # 69

Question/Fact:

A 28-year-old woman is admitted to the hospital after the acute onset of shortness of breath beginning yesterday. Two weeks ago, she fractured her left leg, and it was immobilized in a cast. She has a past medical history of deep venous thrombosis in the right leg two years ago. Her older sister had deep venous thrombosis of the lower extremity last year. On arrival to the emergency room, she has a cough with a small amount of hemoptysis. Her temperature is 100.6 F, blood pressure is 110/80 mm Hg, heart rate is 110/min, and the respiratory rate is 22/min. A venous duplex study shows thrombosis of the popliteal and femoral veins of the left lower extremity. A V/Q scan shows two segmental perfusion defects. The patient is started on intravenous heparin. In four days, her platelet count drops from 183,000 to 110,000 to 44,000/mm3. What is the next step in the management of this patient?

(A) Inferior vena cava filter insertion
(B) Switch to low-molecular-weight heparin
(C) Switch to coumadin
(D) Switch to lepirudin
(E) Continue heparin for three days until coumadin becomes effective

Answer:

(D) Switch to lepirudin

Explanation:

This patient presents with pulmonary thromboembolism, deep venous thrombosis, and most likely, an underlying inherited hypercoagulable state. The course of treatment was complicated by heparin-induced thrombocytopenia (HIT). When a diagnosis of HIT is suspected, heparin should be discontinued immediately. HIT antibodies are associated with both venous and arterial clots, which can occur even after stopping the heparin. For this reason, an alternative form of anticoagulation must be initiated immediately. Lepirudin is an alternative form of anticoagulation that will not interact with the antibodies causing thrombocytopenia. Coumadin (warfarin) is associated with a syndrome of venous limb gangrene when it is administered to patients with HIT; this is due to a decrease in protein C levels. Coumadin should be started after an alternative anticoagulant has been started. Vena caval filter insertion may be used, but it would not do anything to keep the clots in the lungs or the legs from growing. Low-molecular-weight heparins are associated with a lesser risk of HIT, but at least 90% of HIT antibodies cross-react with these compounds.

Record # 70

Question/Fact:

A 56-year-old man with no significant past medical history presents to the emergency room with excruciating pain in his right ankle since this morning. This is the first time this has ever happened to him. He denies any recent trauma of the ankle. He took two tablets of acetaminophen one hour ago without improvement. He is limping because of the pain. The patient had a repair of an anterior cruciate ligament of the right knee two years ago after a car accident. Physical examination reveals a red, swollen, and very tender right ankle joint. His temperature is 102 F. He refuses to allow you to test his range of motion in this joint because any motion is extremely painful. What is the next step in the management of this patient?

(A) Colchicine
(B) Allopurinol
(C) Arthrocentesis
(D) Intra-articular steroid injection
(E) Nafcillin and ciprofloxacin

Answer:

(C) Arthrocentesis

Explanation:

The first step in the management of this patient should be arthrocentesis to distinguish between the two most common forms of monoarticular arthritis. Septic arthritis and crystal-induced arthritis, such as gout or pseudogout, can look quite similar in clinical presentation. They both can give a fever combined with a warm, red, swollen, immobile joint. The ideal therapy for him will be based on the results of the arthrocentesis. The distinction is critical because the drugs used to treat these two types of diseases have no overlap, except for the NSAIDs. Both can give joint effusions with an elevation of the leukocyte count of the synovial fluid. Septic arthritis is more often above 50,000/μL, but there is some overlap at the 30,000 to 50,000/μL range. Blood cultures are usually positive in 50% of patients with septic arthritis. Staphylococcus aureus is the most common cause of nongonococcal septic arthritis, followed by groups A and B streptococci. If this patient has septic arthritis, infusion of steroids into the joint would be potentially harmful, and colchicine would be useless. Gout is diagnosed by finding negatively birefringent, needle-shaped crystals within polymorphonuclear cells in the joint. This criterion is 84% sensitive and 100% specific. Treatment of acute attacks of gout includes rest and control of the inflammation with a short course of NSAIDs. Intra-articular glucocorticoids can be effective in therapy of acute gout in those unresponsive to NSAIDs or colchicine. Identification of calcium pyrophosphate crystals in joint aspirates is diagnostic of pseudogout.

Record # 71

Question/Fact:

A colleague asks you to evaluate a 42-year-old woman with a history of systemic lupus erythematosus (SLE) for the development of a new murmur. She has had a recent increase in her dose of steroids. Her blood pressure is 132/68 mm Hg, with a respiratory rate of 12/min and a temperature of 97.9 F. Cardiac auscultation reveals a 2/6 pansystolic murmur at the apex with radiation to the left axilla. Transesophageal echocardiography reveals vegetations on the anterior leaflet of the mitral valve. There is mild-to-moderate mitral regurgitation and a mild pericardial effusion. Multiple sets of blood cultures are negative for infectious pathogens. Which of the following is most appropriate?

(A) Repeat her examination and echocardiogram in six months
(B) Cardiac catheterization
(C) No further cardiac evaluation is necessary
(D) Change the dose of prednisone
(E) Start ceftriaxone

Answer:

(A) Repeat her examination and echocardiogram in six months

Explanation:

Libman-Sacks endocarditis, also referred to as verrucous endocarditis, is a fairly common complication of SLE. The verrucae consist of accumulations of immune complexes, mononuclear cells, fibrin, platelet thrombi, and hematoxylin bodies and are usually situated near the edge of the valve. The mitral valve is most often involved, followed by the aortic and the tricuspid valves. Scarring, fibrosis, and calcifications are common, and at times can lead to valve deformities and dysfunction, which often present as new murmurs on cardiac examination. The patient in question is asymptomatic, which is typical of most cases of verrucous endocarditis. However, the nature of the disease is not benign, and patients require regular follow-up, including echocardiography. This is done to determine the need for possible valve replacement because of progressive valvular insufficiency. In this case, you are repeating the echocardiogram in six months because of the mitral regurgitation. Systemic embolization and infective endocarditis can develop on valves with pre-existing damage. Cardiac catheterization would not be beneficial in this case and may increase the risk of systemic embolization from the valvular vegetations. Without evidence of infection, including multiple, negative blood cultures, antibiotic therapy would not be beneficial. Not only does the patient have no fever, but there is also no sign of embolic phenomena, such as Roth's spots, Janeway lesions, or Osler's nodes. Finally, steroid and cytotoxic therapy have no effect upon valvular lesions associated with SLE.

Record # 72

Question/Fact:

A 62-year-old man presents to the emergency room with 12 hours of sharp retrosternal chest pain that radiates to the back. The patient states that this pain is similar to what he had experienced two weeks ago, when he had been diagnosed with an acute myocardial infarction. He did not have symptoms of shortness of breath at that time. He is currently experiencing increased chest pain on deep inspiration. The patient also states that he first began to experience the pain while he was lying down. On physical examination, the patient has a low-grade fever of 100.9 F, pulse of 91/min, blood pressure of 110/74 mm Hg, and respirations of 23/min. There is jugular venous distention, decreased breath sounds bilaterally, and an audible friction rub. Laboratory studies show: WBC 16,000/mm3, hemoglobin 10.2 mg/dL, hematocrit 38.8%, and platelets 339,000/mm3. What is the most sensitive and specific diagnostic test for this patient's condition?

(A) Electrocardiogram
(B) Erythrocyte sedimentation rate (ESR)
(C) Transthoracic echocardiogram
(D) Transesophageal echocardiogram
(E) Pericardial biopsy

Answer:

(E) Pericardial biopsy

Explanation:

The patient described in this question presents with Dressler's syndrome, which is often referred to as postcardiac injury syndrome. Dressler's syndrome can occur weeks to several months after a myocardial infarction or open-heart surgery. It can be recurrent and is thought to represent an autoimmune syndrome or a hypersensitivity reaction in which the antigen originates from injured myocardial tissue or pericardium. Circulating autoantibodies to the myocardium frequently occur. Patients typically present with fever, pleuritic chest pain, leukocytosis, and an elevated sedimentation rate. The EKG typically shows diffuse ST-segment elevation in almost all leads, which is consistent with acute pericarditis. Pericardial and pleural effusions are frequently seen as well. Often, no treatment is necessary (aside from aspirin or other nonsteroidal anti-inflammatory agents [NSAIDs]). Glucocorticoids, such as prednisone, are used in those cases not responsive to NSAIDs.

Although EKG, echocardiogram, and ESR should be done as initial tests, the diagnostic test that obtains a sample of tissue is always the most accurate test. Therefore, the tissue diagnosis by biopsy of pericardial tissue is the best answer choice. Although it is the most accurate test, pericardial biopsy is rarely necessary.

Record # 73

Question/Fact:

A 67-year-old white man is admitted to the hospital for epigastric pain associated with nausea, vomiting, flatulence, and a 15-lb weight loss. He claims that he has had a decreased appetite for the past year and attributes the weight loss to his decreased appetite. He also claims that the stool he has been passing smells very foul. He has had multiple admissions for the same problem within the last year. He has a past medical history significant for hypertension, which is controlled with beta-blockers, and diet-controlled diabetes mellitus. He also admits to smoking one pack per day for the last 45 years and was a heavy drinker until he joined Alcoholics Anonymous two years ago.

On physical examination, he is afebrile, heart rate is 82/min, blood pressure is 130/82 mm Hg, and respirations are 18/min. Lungs-air entry is decreased in the right lower lobe. S1 and S2 heart sounds are clearly audible. Abdominal examination shows thin guarding upon palpation of the epigastric area, decreased bowel sounds, and no hepatosplenomegaly. There is no edema or cyanosis in the extremities. His stool is guaiac-negative, but there are no rectal or prostatic masses. Laboratory findings show an amylase of 180 U/L, total bilirubin of 2.0 mg/dL, a direct bilirubin of 1.5 mg/dL, and an alkaline phosphatase of 221 U/L. An ERCP shows a mild constriction of the intrapancreatic bile duct and beading of the pancreatic ducts. He is started on pancreatic enzymes. Which of the following should also be implemented?

(A) Treat this patient with 1 mg morphine intravenously (IV) every 4 hours as indicated for pain with medications for constipation
(B) Treat this patient with 2 mg morphine IV every 4 hours as indicated for pain with medications for constipation
(C) Treat this patient with 50 mg of Demerol every 4 hours as indicated for pain with medications for constipation
(D) Prescribe omeprazole 20 mg before and after meals
(E) This patient must have surgical treatment and cannot be treated with medical therapy only

Answer:

(D) Prescribe omeprazole 20 mg before and after meals

Explanation:

This patient has the signs and symptoms of chronic pancreatitis. He has a history of heavy alcohol intake with recurrent symptoms over the last year. Findings in chronic pancreatitis include compression of the common bile duct, causing increased alkaline phosphatase, glucosuria, and excess fat in feces (therefore explaining the foul smell of his feces). Abdominal x-ray may show calcifications due to pancreatocolithiasis in 30% of patients with chronic pancreatitis. ERCP may show dilated ducts, giving a "chain of lakes" appearance. Intraductal stones, strictures, or pseudocysts may also be found. Alcohol is forbidden. Avoidance of narcotics is also recommended because these patients typically become dependent. With pancreatic enzyme supplementation for steatorrhea (30,000 U of lipase given before, during, and after meals), H2-receptor antagonists or proton-pump inhibitors should be added to prevent inactivation of lipase by gastric acid.

Record # 74

Question/Fact:

A 45-year-old man comes to the clinic with low-grade fever, malaise, and body pain for the last 4 to 5 months. The pain mostly affects the lower extremity joints and calf muscles. He has also had several episodes of abdominal pain, which is associated with nausea and vomiting. There have been a few episodes of rectal bleeding. He has lost 10 to 15 pounds of body weight over the last few months. He denies any major illness or hospitalizations in the past. He has a temperature of 101.0 F, his heart rate is 80/min, and his blood pressure is 150/100 mm Hg. The physical examination is significant for motor and sensory deficits in the right foot. Laboratory studies reveal: white cell count 13,000/mm3, hematocrit 26%, platelets 400,000/mm3, ESR 100 mm/h.

Urinalysis shows proteinuria and microscopic hematuria. There are no significant findings on chest x-ray. Which of the following is the most likely diagnosis?

(A) Wegener's granulomatosis
(B) Polyarteritis nodosa
(C) Microscopic polyangiitis
(D) Churg-Strauss syndrome
(E) Cryoglobulinemia

Answer:

(B) Polyarteritis nodosa

Explanation:

This is a typical case of polyarteritis nodosa (PAN). Patients with PAN are mostly middle-aged adults presenting with fever, malaise, neuropathy, and weight loss. Patients have anemia, leukocytosis, and an elevated ESR. A complication of the disease is focal, segmental, glomerular sclerosis of the kidneys, which causes proteinuria and microscopic hematuria. Measuring the P-ANCA is neither sensitive nor specific for the diagnosis of this disease. The C-ANCA test is far more useful for Wegener's granulomatosis. Wegener's granulomatosis is unlikely because of the absence of lung and upper respiratory disease. Angiography or biopsy of the symptomatic organ is used for the diagnosis of PAN. The histopathology does not show granulomas. Permanent blindness is a feature of giant-cell arteritis, which mostly affects people over the age of 50. Corticosteroids and immunosuppressive agents are used for treatment.

Churg-Strauss syndrome gives asthma, glomerulonephritis, and peripheral eosinophilia. Microscopic polyangiitis should not present with hypertension. The presence of hypertension implies a disease of medium-sized blood vessels. Cryoglobulinemia is associated with chronic hepatitis B and C. It presents with palpable purpura, glomerulonephritis, and peripheral neuropathy. There is usually no gastrointestinal involvement, as described in this case.

Record # 75

Question/Fact:

A 36-year-old woman comes to the emergency department complaining of hand pain and a headache. She states that with a change in weather, her hands start turning a deep blue and provide her with considerable discomfort. She was healthy until a year ago, when she started to notice that her skin was becoming tight and she began to have some difficulty swallowing. She says, "Food gets stuck in the back of my throat." She also complains of headaches, which are throbbing in nature and are located in the frontal sinus region. She denies chest pain and visual changes. Her previous labs four months ago show a hematocrit of 33%, BUN of 10 mg/dL, and a creatinine of 0.9 mg/dL.

Her blood pressure is now 180/120 mm Hg. Physical examination shows generally tight and smooth skin and some ulcerations of her fingertips. No evidence of cyanosis is present on her hands. Current laboratories studies reveal:

Hematocrit 28%; BUN 48 mg/dL; creatinine 3.6 mg/dL.

Rheumatologic studies (ANA, ESR, rheumatoid factor, SCL70) are sent and are not available at this time.

What would be the next step in the management of this patient?

(A) Admit the patient and start prednisone
(B) Discharge the patient with a course of steroids
(C) Admit the patient and start captopril
(D) Discharge the patient on cyclophosphamide
(E) Discharge the patient on nifedipine and metoprolol

Answer:

(C) Admit the patient and start captopril

Explanation:

This patient has scleroderma and is currently noted to be in scleroderma renal crisis. This is evident by an accelerated deterioration in her kidney function and her elevated blood pressure. The best course of action at this time would be to admit this patient and to control her blood pressure with an ACE inhibitor. In spite of the elevated creatinine of 3.6 mg/dL, regulation of blood pressure with ACE inhibitors has been shown to improve the one-year survival in the scleroderma patient population. Steroid therapy plays no role in the treatment of scleroderma. Cyclophosphamide has a limited role in treating scleroderma. It is primarily used in severe interstitial lung disease. Nifedipine would only be useful in managing her Raynaud's syndrome, not the renal failure. Outpatient management of her blood pressure with metoprolol will not prevent progression of her renal failure. This patient also exhibits a number of features of the CREST syndrome, such as calcinosis, Raynaud's phenomena, esophageal dysmotility, sclerodactyly, and telangiectasia.

Record # 76

Question/Fact:

A 38-year-old injection drug user is admitted with fever, cough, weight loss, and sputum production for the past four weeks. His chest x-ray shows a right upper lobe infiltrate, and his sputum smear is positive for acid-fast bacilli. He is started on isoniazid, rifampin, pyrazinamide, and ethambutol. His HIV test comes back positive. His viral load is 250,000, and his CD4 count is 187/μL. You start zidovudine, lamivudine, Bactrim, and nelfinavir. He is in his second week of antituberculosis therapy. What should you do at this time?

(A) Continue the same antituberculosis medications
(B) Change the rifampin to rifabutin
(C) Discontinue ethambutol from the four-drug regime
(D) Stop rifampin
(E) Switch zidovudine to didanosine

Answer:

(B) Change the rifampin to rifabutin

Explanation:

Rifampin is a powerful inducer of hepatic microsomal enzymes and shortens the half-life of HIV protease inhibitors. Rifampin is contraindicated for patients receiving protease inhibitors because it will bring the level of the protease inhibitor below that which will effectively inhibit the growth of the HIV virus. Patient with tuberculosis who must be treated with antiretroviral medications should have rifabutin substituted for the rifampin. Only nefinavir, indinavir, or efavirenz should then be used in combination with the rifabutin. Protease inhibitors inhibit the metabolism of the rifamycin, so the dose of rifabutin has to be decreased when it is used in combination with protease inhibitors. Ethambutol should be continued because it is important to use four drugs at the beginning until the results of sensitivity testing are known. Ethambutol does not interact significantly with protease inhibitors. You should not simply stop rifampin. Rifamycins, such as rifampin and rifabutin, are extremely effective bactericidal drugs against tuberculosis. Without them, the duration of therapy might have to be extended for as long as 18 months. The nucleoside reverse-transcriptase inhibitors, such as zidovudine, lamivudine, and didanosine, have no interactions with rifampin and do not have to be adjusted at any time.

Record # 77

Question/Fact:

A 24-year-old hemophiliac man is admitted to the hospital for a severely swollen and painful left knee. He states that he woke up with the symptoms, which were initially mild but progressively worsened throughout the day. The patient states that he has had similar episodes of joint swelling previously, especially after minor trauma, but he denies any recent trauma. The patient has had numerous episodes of bleeding and hospitalizations. On admission, he appears to be in moderate distress from the knee pain. The patient is well known to the hospital staff because of his previous admissions and is promptly started on factor VIII concentrate. Labs drawn at the time of admission show: hemoglobin 12 g/dL; hematocrit 35.8%; and factor VIII:C level 2.0%.

Twenty-four hours after admission, a repeat set of labs are drawn:

PT 11.0 seconds; PTT 68.3 seconds; factor VIII:C 2.0%; factor VIII antigen normal; bleeding time normal.
A plasma mixing study is performed that fails to correct the PTT.
The Bethesda titer is positive but still low at <5 Bethesda units.

What is the best step in the management of this patient?

(A) Stop factor VIII therapy immediately
(B) Desmopressin acetate
(C) Cyclophosphamide and prednisone
(D) Immunoglobulin therapy
(E) Obtain factor IX levels
(F) Porcine factor VIII

Answer:

(F) Porcine factor VIII

Explanation:

The patient presents with spontaneous hemiarthrosis, which is a classic presentation of patients with severe hemophilia. Depending on the severity of the disease, patients can present with bleeding into the joints, muscles, or gastrointestinal tract. This can occur spontaneously if the factor VIII level is extremely low or after minimal trauma at higher levels of activity. Hemophilia A is seven times more common than is hemophilia B (factor IX deficiency).

The failure of the factor VIII:C level to increase significantly after 24 hours of factor VIII replacement therapy, along with the failure of the PTT to correct on the plasma mixing study, indicate the presence of a factor VIII inhibitor. Antibodies to factor VIII may develop in 15% of patients with hemophilia who have received infusions of factor VIII concentrate. Factor VIII inhibitor may also develop postpartum or could be idiopathic. The treatment of choice is porcine factor VIII. Porcine factors have different antigens compared with recombinant factors. It will not be destroyed by the same anti-factor VIII antibodies that are active against recombinant factor VIII. The Bethesda titer is a way to quantify the amount of factor VIII antibodies present in plasma. The higher the titer, the greater the amount of factor VIII antibody present. When the antibody is present in low titer (<5 Bethesda units) you can raise the factor VIII levels by using the porcine type. When the Bethesda titer is high (>5), you can use factor IX concentrates.

Cyclophosphamide and prednisone as a combination is antiquated therapy. Although they will eventually lower the antibody level, they will not work acutely enough to be very useful to this patient who presents with acute bleeding. Plasmapheresis and aggressive factor VIII therapy are also useful treatments. Immunoglobulin therapy is not currently indicated in the treatment of factor VIII inhibitor. Obtaining a factor IX level is not indicated when we already have a low factor VIII level on record. Desmopressin acetate is used most often in patients with mild hemophilia (factor VIII:C >5%) in preparation for minor surgical and dental procedures. Desmopressin is unlikely to be effective when the factor VIII levels are under 5%.

Record # 78

Question/Fact:

A 78-year-old man came to your office seeking a second opinion regarding his Parkinson's disease (PD). Three years ago he was diagnosed with PD, and despite treatment, his condition became worse. He has an unsteady gait, which has been progressively worse over the past five years. For the past 3 years, he has also had difficulty seeing. He complains of frequent falls, occasional urinary incontinence, and difficulties in maintaining an erection. Both his parents had Parkinson's disease. Physical examination findings are remarkable for postural instability and gait unsteadiness. He has a significant bradykinesia, and the face is hypomimic. The neck has an extended posture, and there is rigidity of the limbs and axial muscles. The speech is dysarthric, and the jaw jerk and gag reflexes are exaggerated. There is paralysis of vertical and horizontal gaze, with preservation of the oculocephalic and oculovestibular reflexes. What is the most likely cause of his condition?

(A) Parkinson's disease
(B) Progressive supranuclear palsy
(C) Shy-Drager syndrome
(D) Postencephalitic parkinsonism
(E) Familial parkinsonism

Answer:

(B) Progressive supranuclear palsy

Explanation:

This patient presents with progressive supranuclear palsy, which accounts for 8% of all parkinsonian patients evaluated in a Parkinson's disease clinic. Progressive supranuclear palsy has an onset after 70 years of age. Initial symptoms consist of a gradual onset of postural instability, unsteady gait, and supranuclear vertical ophthalmoparesis, initially expressed by an impairment of downward gaze. Later, upward and lateral conjugate gaze become impaired. They can exhibit axial rigidity, nuchal dystonia, and a rigid facial expression. Dementia is a sign of late disease. The symptoms don't respond to antiparkinsonian medications.

Record # 79

Question/Fact:

A 57-year-old man is brought to the emergency department after having had a seizure. His wife states that two days ago, he began complaining of a headache and fever and was intolerant to bright light. This morning she noticed he was confused and disoriented. He subsequently developed a tonic-clonic seizure. He has no past medical history and is on no medications. His temperature is 101.2 F, heart rate is 97/min, and blood pressure is 128/85 mm Hg. His pupils are equal and reactive, with normal fundi. There is marked nuchal rigidity.

Upon physical examination, the patient appears confused and disoriented with intact cranial nerves. The lumbar puncture on the day of admission shows a lymphocytic pleocytosis of the cerebrospinal fluid. Gram stain shows no organisms. The patient is then placed on intravenous acyclovir. Later, during the course of this admission, an MRI of the brain shows increased signal uptake of the right temporal lobe. Final analysis of the cerebral spinal fluid (CSF) shows no growth on bacterial or acid-fast cultures. The VDRL and CSF herpes-antibody test are negative. Which of the following is the next best step in the treatment of this patient?

(A) Brain biopsy
(B) Continue the full course of acyclovir and await PCR testing of the CSF
(C) Continue acyclovir and add ceftriaxone
(D) Discontinue acyclovir and start ceftriaxone
(E) Examine CSF for anti-HSV antibodies in four weeks

Answer:

(B) Continue the full course of acyclovir and await PCR testing of the CSF

Explanation:

This patient most likely has herpes simplex virus (HSV) encephalitis. His clinical presentation, cerebral spinal fluid (CSF) analysis, and MRI findings are very characteristic of HSV central nervous system (CNS) infection. Herpes encephalitis usually presents with fever, confusion, a mild lymphocytic pleocytosis, and temporal lobe involvement on brain scan. In cases like this, the HSV polymerase chain reaction (PCR) would usually be positive in 95 to 98% of patients. In cases where there is a high clinical suspicion of HSV encephalitis, the only indication to stop the course of acyclovir is a negative brain biopsy or a negative herpes DNA, PCR test. There is rarely a need to perform a brain biopsy to exclude herpes encephalitis because of the exquisitely high sensitivity of the PCR test. Antibodies to HSV will rise in the CSF in patients with HSV encephalitis, but rarely before 10 days of illness. The question, however, states that he had a negative antibody test, not a negative PCR for herpes DNA.

Record # 80

Question/Fact:

A 51-year-old stockbroker comes to your clinic for a yearly check up. His only complaint is chronic constipation. He is mildly concerned about his health and mentions having had high cholesterol 2 years ago. He was advised at that time to stop smoking and reduce his intake of fatty foods. The patient stopped smoking but continues to be overweight. His 50-year-old brother suffered from a "heart attack" last year. On physical examination, blood pressure is 170/90 mm Hg, pulse is 85/min, and his abdomen is obese. A nonfasting cholesterol level is 330 mg/dL, and you schedule him for a fasting lipid profile test in 2 days.

On Day 3 the results are as follows:

Cholesterol 280 mg/dL
LDL 165 mg/dL
HDL 32 mg/dL
Triglycerides 262 mg/dL

What is the next step in the management of this patient?

(A) No therapy indicated
(B) Dietary therapy only
(C) Cholestyramine
(D) Statin therapy
(E) Gemfibrozil

Answer:

(D) Statin therapy

Explanation:

This patient has four separate risk factor for coronary artery disease and an LDL above 160 and should be started on lipid-lowering drug therapy in addition to dietary modification and exercise. His risk factors are hypertension, age >45 years, being male, an HDL <40 mg/dL, and a family history significant for premature coronary artery disease. Statins are generally the first choice for initial therapy because they have the best evidence for a reduction in mortality. In addition, this patient is already suffering from constipation, and one of cholestyramine's most common adverse effects is constipation.
 
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* Re:For ppl. don't have these MCQ's........
#1186841
  aiissman - 02/25/08 17:30
 
  brainX Digital Learning System
Study Session of KnowledgeBase: Practice Exam 3

Record # 1

Question/Fact:

A 56-year-old man presents to the clinic with complaints of fatigue for the past 2 months. He has a history of iron-deficiency anemia. Currently, he is on iron supplements. He denies nausea, vomiting, and diarrhea and has one to two, formed, brown bowel movements per day. He denies weight loss. He has a history of hypertension, which has been controlled on medications. Physical examination is remarkable for pale sclera. Otherwise, the examination is normal. Stool occult blood test is negative, and an upper endoscopy is normal. The colonoscopy revealed a 4-mm polyp that was noted to be hyperplastic on biopsy. Laboratory studies show a hematocrit of 29%. Iron studies are as follows: serum iron 7 μmol/L (normal 9-31 μmol/L), ferritin 14 (normal 16-300 μg/mL), and total iron-binding capacity 92 μmol/L (normal 45-82 μmol/L). Which of the following is the next best step in management?

(A) Repeat fetal occult blood test, upper endoscopy, and colonoscopy
(B) Increase dose of iron therapy
(C) Mesenteric angiogram
(D) Serology testing for IgA antiendomysial antibody
(E) Quantitative analysis of fecal fat

Answer:

(D) Serology testing for IgA antiendomysial antibody

Explanation:

Celiac disease, or sprue, is characterized by flattened duodenal villi, decreased small-bowel absorption, and antiendomysial and antigliadin antibodies. The disease can present as iron-deficiency anemia of unclear etiology. The diagnosis can be made by upper endoscopy if biopsies are taken of the duodenum (not typically performed). In the absence of biopsies, the duodenal mucosa could appear normal to the eye. The diagnosis can also be obtained with IgA antiendomysial antibodies. Due to the prevalence of selective IgA deficiency in patients with celiac disease, antigliadin antibodies should also be obtained.

Topic:

Gastroenterology

Record # 2

Question/Fact:

A 25-year-old man comes to your clinic stating that he can no longer take his seizure medication because his gums "look horrible." He is seeing you for the first time. He has been on phenytoin 100 mg, three times a day, for the last 6 years for generalized tonic-clonic seizures. Despite therapeutic levels of phenytoin, he also experiences occasional jerking of his extremities and has spells in which he "blanks out" for a few seconds. His physical examination shows gingival hyperplasia. His neurological exam is within normal limits. An MRI of his head was normal two years ago. Also, an EEG performed one year ago showed generalized spike and wave abnormalities. What is the most appropriate recommendation at this time?

(A) Start gabapentin and taper the phenytoin
(B) Discontinue phenytoin and switch to carbamazepine
(C) Increase the dose of phenytoin from 300 to 400 mg daily
(D) Serum phenytoin level and liver function tests should be obtained and the dosage adjusted
(E) Add valproic acid and taper the phenytoin
(F) Continue the phenytoin and tell him not to operate a moving vehicle for at least one year

Answer:

(E) Add valproic acid and taper the phenytoin

Explanation:

This patient has generalized tonic-clonic seizures, as well as myoclonic and absence seizures. The phenytoin should definitely be discontinued and another medication should be started because this is a young patient in whom toxicity has already developed. The patient already has a therapeutic level of phenytoin, so there is no point in simply increasing the dose. He will probably stop it on his own anyway. Gabapentin and carbamazepine are not good options in this case because they are not particularly effective in myoclonic and absence seizures. Valproic acid is the only antiepileptic listed in the answer choices that is effective for generalized epilepsy when it is associated with multiple-seizure types, such as myoclonic and absence seizures. When you have a mixed seizure disorder, valproic acid is the most effective therapy. The law in many states is that patients should be told not to operate moving vehicles unless they are free from seizure activity for at least one year. This discussion with the patient should be documented in your progress note. Health care professionals are not required to notify law enforcement officials or health care agencies. Although he shouldn't drive, you can't just simply continue the phenytoin. You need to control his disease, which is breaking through the phenytoin, and he has adverse effects from it that compel a switch in therapy.

Topic:

Neurology

Record # 3

Question/Fact:

A 58-year-old man was admitted this evening due to a syncopal episode after walking up a flight of stairs. The patient denied having chest pain, palpitations, diaphoresis, or any unusual sensations before the episode. He does have a chronic cough and progressive dyspnea on exertion. He denies smoking and alcohol or drug abuse. Physical examination reveals an afebrile, overweight man, with respiratory rate of 30/min, blood pressure of 100/75 mm Hg with no change on inspiration but a drop to 90/65 mm Hg while upright. His heart rate is 58/min.

Physical findings include the presence of jugular venous distention (JVD) not changing with inspiration, and distant heart sounds with the presence of an S3 gallop but no audible murmurs. There are bibasilar crepitations on respiratory examination, an enlarged tongue, and hepatosplenomegaly with the presence of shifting dullness on abdominal examination. Stool is negative for blood, and there is a 2+ pitting edema of both lower extremities. An EKG reveals low QRS voltage with a right bundle branch block but no ST-T changes or Q waves. Chest x-ray reveals mild pulmonary congestion with bilateral pleural effusions. The heart size is normal. What would be the most likely finding on echocardiogram?

(A) Pericardial effusion
(B) Thickened heterogenous/granular myocardium with bi-atrial enlargement
(C) Thickened pericardium
(D) Left and right ventricular dilatation and hypocontractility with an ejection fraction of 35%
(E) Left ventricular hypertrophy with asymmetric ventricular septal hypertrophy (septal-posterior wall thickness ratio of 1.6)

Answer:

(B) Thickened heterogenous/granular myocardium with bi-atrial enlargement

Explanation:

Syncope, dyspnea, chest pain, and elevated right-sided pressures producing congestive heart failure (CHF) symptoms may be characteristic of many conditions, such as cardiomyopathy of any type, pericarditis, cardiac tamponade, and cardiac ischemia. This patient has restrictive cardiomyopathy secondary to amyloidosis. Restrictive cardiomyopathy is characterized mostly by decreased distensibility (diastolic dysfunction) with preservation of cardiac output until the disease is advanced. Classically, cardiac amyloidosis is "nondilated" with normal ventricular dimensions. It is commonly associated with congestive symptoms of right heart failure. An enlarged tongue is characteristic. Amyloidosis is the most common cause of infiltrative cardiomyopathy. Deposits frequently affect the conduction system, leading to bradyarrhythmias and conduction blocks. Amyloid also surrounds the arterioles, which may compromise the microcirculation, leading to anginal chest pain, which is frequently atypical. Syncope may be the initial presentation due to sinus or atrioventricular node involvement or orthostatic hypotension due to amyloid autonomic neuropathy. The EKG characteristically shows markedly decreased voltage and a bundle branch block. Amyloidosis gives echocardiographic findings of abnormal myocardial relaxation and decreased diastolic filling with a near-normal ejection fraction. You also find a heterogeneously thickened myocardium with a "speckled" appearance of the ventricular wall from the amyloid infiltration. Pericardial effusion would be seen with pericardial tamponade. Tamponade is characterized by pulsus paradoxus, which is a decrease in systolic arterial pressure greater than 10 mm Hg on inspiration. This patient has no changes of the jugular veins on inspiration. Thickened pericardium is diagnostic of chronic, constrictive pericarditis, which results from the healing of acute pericarditis. On physical examination in constrictive pericarditis, one would find Kussmaul's sign, a pericardial knock, and a reduced apical pulse. EKG may display low QRS voltage.

Left and right ventricular dilatation, hypocontractility, and an ejection fraction of 35% are characteristic of dilated cardiomyopathy. However, in this type of cardiomyopathy, severe symptoms of CHF do not occur early and are usually present when the ejection fraction is <30%. The usual history for a patient with dilated cardiomyopathy is gradual exertional intolerance and an onset of congestive symptoms. The heart size would be increased on the chest x-ray in this condition.

Asymmetric ventricular septal hypertrophy with the septum/posterior wall-thickness ratio of >1.3 is characteristic of hypertrophic cardiomyopathy. Most patients with this cardiomyopathy present between the ages of 20 and 40 and rarely past 50, such as in this patient's case. On physical examination, the physician would find a prominent ventricular impulse. Decreased left ventricular compliance may lead to an S4 and a harsh murmur at the left lower sternal border that worsens with Valsalva and improves with leg raise. EKG abnormalities most commonly include left ventricular hypertrophy and prominent Q waves.

Topic:

Cardiology

Record # 4

Question/Fact:

A 28-year-old woman comes to your clinic for vaginal discharge and dyspareunia. Her last pelvic exam and Pap smear six years ago were normal. Her only medication is oral contraceptives. She is sexually active with one partner and denies a history of sexually transmitted diseases. Examination of the pelvis reveals a mucopurulent, nonodorous, whitish discharge at the endocervical os. The cervix appears edematous and erythematous with minimal bleeding noted with scraping. What is the next appropriate step in the management of this patient?

(A) Doxycycline
(B) Azithromycin and ceftriaxone
(C) Metronidazole
(D) Wait for culture and immunofluorescence testing results
(E) Azithromycin

Answer:

(B) Azithromycin and ceftriaxone

Explanation:

This patient presents with cervicitis and a mucopurulent discharge found on pelvic exam. The presence of white blood cells is also often found on endocervical Gram stain, which would also support the diagnosis. This is too nonspecific to be useful in guiding the choice of a single specific therapy. All forms of cervicitis will give white cells on a Gram stain of the cervix. Edema of the cervix with the propensity of the mucosa to bleed on minor trauma is common with cervicitis. These findings are commonly found in association with both chlamydial and gonococcal infection. Empiric therapy for both diseases is indicated. You can't just treat the chlamydia. This patient has a clear diagnosis of cervicitis because of the discharge and dyspareunia, combined with a cervical discharge. Chlamydia can be treated either with a single dose of azithromycin or with doxycycline for a week in those patients with cervicitis or urethritis. Gonorrhea can be treated with a single dose of ceftriaxone, cefixime, or a fluoroquinolone, such as ciprofloxacin, levofloxacin, or ofloxacin. The quinolones are associated with more resistance than the cephalosporins.

Topic:

Infectious Diseases

Record # 5

Question/Fact:

A 56-year-old man is admitted to the hospital for elective cardiac bypass surgery.

As part of his preoperative evaluation, you note an elevated alkaline phosphatase. The other liver function studies are within normal limits. Serum calcium and phosphate are within normal limits. The patient denies any history of bone pain, and the physical examination is normal. What is the next step in the management of this patient?

(A) Obtain a radiologic bone survey
(B) Order a nuclear bone scan
(C) Begin risedronate orally
(D) Order a 24-hour urine test for hydroxyproline
(E) Begin intranasal calcitonin

Answer:

(A) Obtain a radiologic bone survey

Explanation:

The best initial test for the diagnosis of Paget's disease is the radiologic bone survey. Nuclear bone scan and urine for hydroxyproline are more sensitive for active disease but would only be done after a nondiagnostic bone survey. Patients who have an isolated rise in bone-specific alkaline phosphatase and are asymptomatic are likely to have Paget's disease of the bone. The treatment of choice is an oral bisphosphonate, but therapy is only initiated when the patient has symptomatic disease or diffuse cranial involvement. Calcitonin is no longer the first-line therapy for treatment of Paget's disease because it is less effective, difficult to administer, and can cause unpleasant side effects (nasal irritation and epistaxis).

Topic:

Endocrinology

Record # 6

Question/Fact:

A 21-year-old woman presents with a history of ulcerative colitis and insulin-dependent diabetes mellitus. She is admitted for a diabetic foot ulcer and is started on cefotetan. On the day of admission, her colitis flares up, and she has seven episodes of diarrhea. She stops eating, fearing that food may exacerbate her symptoms. She also develops a headache for which she takes acetaminophen every four hours. Four days after the admission, she starts having a nosebleed, which stops with nasal packing. The following day, while ambulating, the patient trips and falls against a chair, resulting in a bruise that develops into a large hematoma. She denies easy bruising or excessive bleeding during dental procedures in the past.

Laboratory studies show the following results:

WBC 6,200/mm3; hemoglobin 9.6 mg/dL; hematocrit 27.5%, platelets 300,000/mm3. Bleeding time 3 minutes (normal); PT 18 seconds; INR 1.5; PTT 42 seconds; albumin 3.5g/dL; total bilirubin 1.2 mg/dL; alkaline phosphatase 95 U/L; ALT 32 U/L; AST 2 5 U/L; ESR 70 mm/h.

What would be the most appropriate in treating this hemostatic disorder?

(A) Desmopressin acetate
(B) Vitamin K
(C) Factor VIII
(D) Fresh frozen plasma
(E) Aminocaproic acid

Answer:

(B) Vitamin K

Explanation:

This patient has vitamin K deficiency based on the recent onset of an increase in bleeding combined with a normal platelet count and an increase in PT, PTT, and INR. She is receiving cefotetan, a cephalosporin known to interfere with the vitamin K-dependent production of clotting factors, and she has not eaten for several days. Antibiotics of any kind can kill off colonic bacteria that produce vitamin K. In addition, the flare-up of colitis will interfere with the absorption of fat-soluble vitamins, such as vitamin K. She does not seem to have significant liver disease based on the normal liver function tests.

A mixing study, which uses one part patient plasma and one part normal plasma, would allow us to differentiate between a factor deficiency and an inhibitor of the coagulation process. Patients who have a factor deficiency resulting in prolongation of the PT/PTT always have correction of the abnormal PT/PTT to normal in a mixing study. Those with antibody inhibitors present do not have correction. Factor VII is vitamin K-dependent and has the shortest plasma half-life. When a patient has vitamin K deficiency, the first abnormality is a prolongation of the PT. In adults with normal hepatic function, vitamin K usually corrects the clotting time within 24 hours.

Desmopressin, a synthetic derivative of vasopressin, promotes the release of von Willebrand's factor and factor VIII from subendothelial stores and is the first treatment for von Willebrand's disease and very mild hemophilia. Although our patient had epistaxis, she did not have a prolonged bleeding time, and this is her first episode of increased bleeding, thus making von Willebrand's disease unlikely.

Factor VIII concentrates are used in patients with hemophilia A who develop bleeding. Hemophilia is very rare in women because it is an X-linked recessive disorder and should present with a prolonged PTT and a normal PT. Fresh frozen plasma is used in severe liver disease or vitamin K deficiency when it presents with very severe bleeding, such as melena or intracranial bleeding. Aminocaproic acid is an inhibitor of fibrinolysis and is occasionally used in disorders such as DIC.

Topic:

Hemotology-Oncology

Record # 7

Question/Fact:

A 43-year-old man who recently relocated to your area presents with four months of blood in his urine, cough, weight loss, and low-grade fever. The physical examination is remarkable for nasal deformity and otitis media. A C-ANCA test is positive. What is best initial therapy for this patient?

(A) Methotrexate
(B) Prednisone
(C) Cyclophosphamide
(D) Prednisone and cyclophosphamide
(E) Trimethoprim/sulfamethoxazole

Answer:

(D) Prednisone and cyclophosphamide

Explanation:

Wegener's granulomatosis is characterized by granulomatous vasculitis of the upper and lower respiratory tract and kidneys. The most definitive diagnosis is by biopsy of the lung or upper respiratory tract. C-ANCA is very sensitive and specific in detecting the disease but is not sufficient alone to establish a diagnosis. The most effective treatment for the disease is prednisone combined with cyclophosphamide. The steroids should be tapered after one month to alternate day dosing and eventually stopped. The cyclophosphamide should be continued for one year. Cyclophosphamide can cause cystitis, bladder cancer, and myelodysplasia. The alternate therapy for those who develop serious toxicity is methotrexate combined with prednisone. Methotrexate leads to remission in many patients. Trimethoprim/sulfamethoxazole is helpful in maintaining patients in remission but is not useful in those with serious, life-threatening disease.

Topic:

Rheumatology

Record # 8

Question/Fact:

A 65-year-old woman with a past medical history of congestive heart failure (CHF) presents with shortness of breath for one day. On further questioning, the patient describes waking in the night unable to breathe. She has been using three pillows to sleep for the past month. She has been hospitalized for this problem twice in the past year and has been noncompliant with her medications, which are furosemide, lisinopril, metoprolol, and aspirin. Physical examination shows: temperature 99 F, respiratory rate 26/min, blood pressure 180/100 mm Hg, and pulse 72/min. Jugulovenous distension is present, as well as an S3 gallop, a III/VI systolic murmur radiating to the axilla, and a displaced point of maximal impulse. The lungs have rales bilaterally, and there is a 2+ pitting edema of the extremities. The BUN is 29 mg/dL, and the creatinine is 1.4 mg/dL.

You treat the patient with intravenous diuretics, nitrates, and morphine. One day after the hospitalization, she is much improved and is ready to be discharged. Which of the following is most likely to decrease mortality in this patient?

(A) Adding irbesartan
(B) Spironolactone
(C) Hydralazine and isosorbide dinitrate
(D) Dobutamine
(E) Amlodipine

Answer:

(B) Spironolactone

Explanation:

Angiotensin-receptor blockers, such as losartan, irbesartan, candesartan, or telmisartan, are used predominantly in patients who cannot tolerate ACE inhibitors because of cough. Angiotensin-receptor blockers will not definitely lower mortality when added to a patient already on ACE inhibitors. Hydralazine and nitrates lower mortality but not as much as the ACE inhibitors. Dobutamine is a positive inotrope that can be used to acutely manage patients with severe, acute exacerbations of congestive failure, such as pulmonary edema. There is no definite evidence that it lowers mortality, and it is a temporary measure for acutely unstable patients who do not respond well to initial therapy with diuretics, oxygen, nitrates, and morphine. Amlodipine is a calcium-channel blocker that does not reliably lower mortality. Spirinolactone helps block the renin-angiotensin system and has been definitely shown to lower mortality in CHF when used on a long-term basis.

Topic:

Cardiology

Record # 9

Question/Fact:

A 28-year-old man with a history of depression is brought to the emergency department after being found in his garage in a drunken state. He is lethargic and smells of alcohol. His fundi appear normal, and so does the rest of his physical examination. An ethanol level is 50 mg/dL, and his osmolar gap is 20 mOsm/kg. His anion gap is 14, which rises to 17 over several hours. His urinalysis appears to be fluorescent under an ultraviolet lamp. An EKG shows sinus tachycardia. Treatment is initiated with intubation followed by gastric lavage, and he is also given thiamine and dextrose. What would be the next best line of management?

(A) Activated charcoal
(B) Chlordiazepoxide
(C) Diazepam
(D) 10% ethanol intravenously
(E) Hemodialysis

Answer:

(D) 10% ethanol intravenously

Explanation:

This was a suicide attempt with ethylene glycol, commonly found in antifreeze. Symptoms range from headaches, nausea, and vomiting to seizures, coma, and renal failure. There are no visual symptoms like you would find with methanol intoxication, whose metabolites can result in optic neuritis, leading to blindness. The retina in that case appears bright red. With ethylene glycol, an osmolar gap is present and, after being metabolized to oxalic acid in toxic levels, can produce severe acidosis. Crystals of calcium oxalate may be seen in the urine. The resultant hypocalcemia presents as a prolonged QT interval on an EKG. The urine may be fluorescent under an ultraviolet lamp owing to fluoresceins added to commercial antifreeze products. In this particular case, the ethanol level does not correlate with the osmolar gap, which is the difference between the measured serum osmolar gap and the calculated osmolality. An elevated DOsm suggests a high level of low-molecular-weight substances, such as alcohol, in the serum.

Treatment is the same for methanol and ethylene glycol intoxication. Ten-percent ethanol infusion is maintained to a level of clinically evident intoxication. Ethanol is preferentially metabolized by alcohol dehydrogenase, and, in cases of severe intoxication with levels above 100 mg/dL or with severe acidosis, this must be combined with hemodialysis. The ethanol does not remove the substance from the body; it merely prevents the production of toxic metabolites. Activated charcoal is poorly adsorbed by alcohols and is not very useful in this case. Chlordiazepoxide is used for the alcohol-withdrawal syndrome. Diazepam is would be used for acute seizures.

Topic:

Poisoning

Record # 10

Question/Fact:

A 55-year-old woman presents to your office complaining of fatigue and pruritus, which is predominantly of the palms and soles. The physical examination shows bilateral xanthelasmas and hepatomegaly. Labs show bilirubin as normal, AST/ALT as normal, cholesterol as elevated, and alkaline phosphatase also elevated. Sonogram shows hepatomegaly. Which test would be the most appropriate to guide us to a diagnosis of her disease?

(A) Antinuclear antibody
(B) Hepatitis B surface antigen
(C) Hepatitis C antibody
(D) Anti-smooth muscle antibody
(E) Antimitochondrial antibody

Answer:

(E) Antimitochondrial antibody

Explanation:

This patient presents with primary biliary cirrhosis. This is an autoimmune disease that initially presents with pruritus predominantly affecting the palms and soles due to the deposit of bile acids from cholestasis. It would be unusual for chronic hepatitis B or C to present with an isolated elevation of the alkaline phosphatase and pruritus as the only symptom. The antinuclear antibody (ANA) would be useful in diagnosing autoimmune hepatitis. The treatment of primary biliary cirrhosis is initially with bile-acid sequestering resins, such as cholestyramine or colestipol.

Topic:

Cardiology

Record # 11

Question/Fact:

A 34-year-old pregnant woman presents to the emergency room with her husband. Her husband claims that she needs to talk to a psychiatrist immediately because he often catches her eating their child's clay. She admits to eating clay occasionally but cannot explain why she does it. She claims that she has been tired for the past 7 months but has attributed it to the pregnancy. She denies any past medical history and does not take any medications. She claims she was given a prescription for vitamins by her obstetrician but was unable to fill it because her husband lost his job and his health benefits. She was trying to improve her nutrition, but often finds herself desiring to eat clay, lettuce, or ice chips. Her blood pressure is 110/70 mm Hg, and pulse is 72/min. Her stool is guaiac-negative, and her skin is pale. Laboratory studies reveal: hemoglobin 9 g/dL; hematocrit 27%; MCV 80 µm3; platelet 280,000/mm3. Her red-cell distribution width is 18%. What is the best management for this patient's anemia?

(A) Prenatal vitamins with iron supplementation
(B) Transfusion
(C) Intramuscular iron injection
(D) Upper endoscopy
(E) Erythropoietin

Answer:

(A) Prenatal vitamins with iron supplementation

Explanation:

This patient presents with anemia that is most likely secondary to iron-deficiency anemia from pregnancy. A normal nonmenstruating, nonpregnant person only requires one milligram per day of iron. When pregnant, this requirement can raise to 4 to 5 mg per day. The intestinal system usually cannot absorb more than 3 to 4 mg per day; therefore, pregnant women are routinely anemic. Although the mean corpuscular volume (MCV) is at the low end of normal, she can still be iron deficient. The older cells will be normal, and the newer cells will be iron deficient. Therefore, the RDW shows the difference in the size of the cells. The average cell size (MCV) may still be normal because it is an average of both the older and the newer cells. Although she is tired, she is not severely symptomatic enough to need a transfusion or intramuscular iron injections. Upper endoscopy would not be useful unless she had hematemesis or some other indication of upper gastrointestinal tract bleeding. Erythropoietin will not be helpful in anemia related to pregnancy because this problem is based on a deficiency of iron. The pica described in the question of eating clay, lettuce, and ice chips is a manifestation of the iron deficiency.

Topic:

Hematology-Oncology

Record # 12

Question/Fact:

An 80-year-old man presents to the emergency department after an episode of loss of consciousness witnessed by his family. This happened while he was sitting in a chair, and it lasted for thirty seconds with a rapid recovery. There were no warning symptoms, convulsions, or neurological deficits afterward. The past medical history is significant for a myocardial infarction two years ago, prostatic hypertrophy, and recurrent episodes of loss of consciousness. The patient is on atorvastatin, metoprolol, enalapril, spironolactone, and tamsulosin. One month ago, a tilt-table study was normal. Echocardiogram showed moderately decreased left ventricular systolic function. An EKG in the emergency department shows a normal sinus rhythm. His blood pressure is 120/70 mm Hg while lying flat and 118/68 mm Hg while sitting up. His heart rate is 68/min and does not change with a shift in position. The rest of the physical examination is unremarkable. What is the best next step?

(A) CT scan of the head
(B) Holter monitor
(C) Carotid Doppler studies
(D) Electrophysiological studies
(E) No further evaluation is necessary

Answer:

(B) Holter monitor

Explanation:

Holter monitor or monitoring in a telemetry unit should be done first to see if the patient is having an arrhythmia as the cause of his syncope. Seventy-two-hour monitoring does not increase the yield in addition to that found on a 24-hour monitor. Cardiac electrophysiological studies are used to assess sinus node function, AV conduction, and to induce supra- or ventricular tachycardia. They are indicated in patients with episodes of syncope and a nondiagnostic ambulatory EKG. Disorientation, convulsions, aura, and incontinence would suggest a seizure. In that case, a CT scan of the head would be indicated. This patient had syncope and might have episodes of sustained ventricular tachycardia that might need the placement of an implantable cardiac defibrillator. For this reason, you cannot just ignore the episode and do nothing. Even without syncope, if the patient has had a previous infarction and an ejection fraction of <30%, an implantable defibrillator may be indicated to prevent sudden cardiac death. Carotid Doppler studies will add little or nothing to the diagnosis of syncope. Doppler studies are indicated in patients who have embolic stroke, TIA, or amaurosis fugax to determine if a patient needs an endarterectomy. Carotid stenosis rarely leads to syncope. It is stenosis of the vertebral and basilar artery system that can lead to syncope.

Topic:

Cardiology

Record # 13

Question/Fact:

A 35-year-old man comes to the office seeking treatment for one week of joint pain in his left knee and right ankle. On further questioning, he admits to soreness of his back, which is tolerable at this time. On physical examination, there is a moderate left-knee effusion and a swollen, tender, right ankle. There are also small pits in the fingernails. What other finding would help make a specific diagnosis?

(A) Positive HLA-B27 antigen
(B) Tender right Achilles tendon
(C) Narrowing and sclerosis of sacral ileac joint
(D) Silver, scaly patches on the extensor surface of forearm and scalp
(E) Spondylitis

Answer:

(D) Silver, scaly patches on the extensor surface of forearm and scalp

Explanation:

This patient presents with one of the seronegative spondyloarthropathies (ankylosing spondylitis, Reiter's syndrome, psoriatic arthritis, and dysentery-related reactive arthritis). They can all present with a positive HLA-B27 antigen and enthesopathic changes, such as an inflammatory process of tendons and ligaments. This is most commonly the Achilles tendon. There is also sacroiliitis, which is seen on x-ray as narrowing and sclerosis of the sacroiliac joint. This patient may have all of these characteristics, but pitting of the fingernails is only specific for psoriatic arthritis. The specific finding on physical examination with psoriatic arthritis is silvery, scaly skin patches on the extensor surfaces of the forearms and scalp. In other words, you should look for evidence of psoriasis to confirm a diagnosis of psoriatic arthritis. The other answers in the question are common to all the seronegative spondyloarthropathies.

Topic:

Rheumatology

Record # 14

Question/Fact:

A colleague asks you to evaluate a 62-year-old woman for occasional palpitations and dizziness for the past two years. An event monitor was used, which recorded several short runs of monomorphic ventricular tachycardia and during which the patient noted palpitations and dizziness. Six months ago, the patient underwent a cardiac catheterization, which was essentially normal. Her past medical history is significant only for a hysterectomy. Her blood pressure is 132/66 mm Hg, heart rate is 72/min, and respirations are 14/min. The physical examination is normal. All recent laboratory tests, including thyroid, cholesterol, and electrolytes are within normal limits. The EKG reveals a normal sinus rhythm at 70/min. An echocardiogram is normal. Which of the following statements is true regarding this patient?

(A) The patient should be reassured and sent home on a beta-blocker
(B) The patient's condition is associated with a high incidence of sudden cardiac death
(C) The patient requires electrophysiologic studies (EPS)
(D) Placement of an implantable defibrillator is indicated
(E) Stress echocardiography is indicated at this time to assist in the management of this patient's condition

Answer:

(A) The patient should be reassured and sent home on a beta-blocker

Explanation:

In patients with monophasic or uniform ventricular tachycardia (VT) and no evidence of structural heart disease, the overall prognosis is good, and the risk of sudden cardiac death is extremely low. This is in contrast to patients with VT and structural heart disease, or patients that are post-myocardial infarction, in which case the risk of sudden death is significantly increased. The disease process in this patient is generally benign and may not require treatment or further work-up. However, because of the brief episodes of tachycardia, patients often become symptomatic and benefit from therapy with a beta-blocker. Other agents that are used for control of symptoms in such patients include verapamil, classes IA, IC, III agents, or amiodarone. Because of the benign nature of this patient's disease process, further evaluation, such as electrophysiologic studies or stress echocardiography, is not indicated. For the same reasons, the placement of an implantable defibrillator device would not be appropriate in the management of this patient at this time.

Topic:

Cardiology

Record # 15

Question/Fact:

A 57-year-old alcoholic man is admitted for the sudden onset of shortness of breath with a clear lung examination. He has a history of severe erosive gastritis. The blood gas shows a pO2 of 72 mm Hg and a markedly elevated A-a gradient on room air. The chest x-ray is normal. He is started on intravenous heparin and six hours later develops black stool and tachycardia. What is best therapy for this patient?

(A) Inferior vena cava filter placement
(B) Intravenous H2 blockers
(C) Embolectomy
(D) Switch to low-molecular-weight heparin
(E) Switch to coumadin
(F) Intravenous proton-pump inhibitors

Answer:

(A) Inferior vena cava filter placement

Explanation:

This patient has a pulmonary embolus and has developed potentially life-threatening bleeding on heparin. You cannot continue anticoagulation in the patient, and coumadin and low-molecular-weight heparin are inappropriate. He does not have severe enough disease or hemodynamic instability, and so embolectomy is inappropriate. Although he has an elevated A-a gradient, his pO2 on room air is only 72 mm Hg. Intravenous H2 blockers are useless in acute gastrointestinal bleeding. Although intravenous proton-pump inhibitors are useful, they will not keep him from dying of a pulmonary embolus. A vena cava filter will prevent further emboli to the lungs; it is indicated either when a patient has a recurrent embolus while on heparin or when there is a contraindication to heparin, such as life-threatening gastrointestinal or intracranial bleeding.

Topic:

Pulmonary

Record # 16

Question/Fact:

A 35-year-old man with a history of Addison's disease presents to the emergency department complaining of nausea, vomiting, and generally not feeling well for a week. He began having a cough with brownish sputum and felt feverish, with chills starting about a week ago. Yesterday, the patient began having increasing weakness, abdominal pain, and diarrhea. His wife also adds that at times he gets confused and doesn't realize where he is. His only medication is hydrocortisone 15 mg daily. His temperature is 102.7 F, with a heart rate of 116/min, a blood pressure of 89/53 mm Hg, and a respiratory rate of 25/min. He has dry mucous membranes, and bronchial sounds are heard over the right lung. The abdomen is diffusely tender to palpation, and there is no rebound tenderness. His white cell count is 18,200/mm3, sodium 126 mEq/L, potassium 5.6 mEq/L, bicarbonate 24 mEq/L, BUN 32 mg/dL, creatinine 1.1 mg/dL, and glucose 72 mg/L. The chest x-ray shows a right middle-lobe infiltrate. What is the most urgent initial step in the management of this patient?

(A) ACTH stimulation test
(B) Increase his dose of hydrocortisone to 30 mg daily
(C) Start antibiotics
(D) Stat dose of hydrocortisone 100 mg intravenously
(E) CT scan of the chest and abdomen

Answer:

(D) Stat dose of hydrocortisone 100 mg intravenously

Explanation:

This patient is in an acute adrenal crisis. He has a background of chronic adrenal insufficiency (Addison's disease), which is well controlled with his standing dose of hydrocortisone. When he became acutely ill with community-acquired pneumonia, his corticosteroid requirements increased due to the increase in his metabolic demands during an acute illness. His adrenal crisis manifested as abdominal symptoms, weakness, confusion, hypotension, hyponatremia, hyperkalemia, and hypoglycemia. As this is a potentially life-threatening condition, the most appropriate next course of action is to give the patient an immediate dose of steroids.

Although an ACTH stimulation test may support your diagnosis, it would not be appropriate in this acute setting. The patient already has a known history of Addison's disease. Although it is important to begin antibiotics promptly, it would not be as immediately lifesaving as giving a dose of steroids would be. The steroids will directly address the patient's hemodynamic instability. In the future, the patient should wear a med-alert bracelet, indicating the presence of Addison's disease. If he presents again with signs of hemodynamic instability to a hospital that does not know him and he is too unstable to offer a history, this could be lifesaving.

Topic:

Endocrinology

Record # 17

Question/Fact:

A 65-year-old obese man is transferred to the telemetry unit because he experienced an episode of atrial fibrillation with a rapid ventricular response while undergoing dialysis. The nurse calls you to the bedside because she was alerted that he had an episode of ventricular tachycardia for about 10 seconds. The telemetry reading shows multiple episodes of premature ventricular complexes over the last 24 hours. His past medical history is significant for diabetes mellitus, hypertension, and chronic renal failure. He feels well. His physical examination reveals a pulse of 93/min, a blood pressure of 110/83 mm Hg, and a normal respiratory rate. There are chronic venous changes and pitting edema on the lower extremities with a glove and stocking-like distribution of sensory deficit. Laboratory studies show: potassium 3.9 mEq/L, BUN 30 mg/dL, creatinine 3.6 mg/dL, and glucose 30 mg/dL. Echocardiography performed a month ago shows an ejection fraction of 54% and normal left ventricular function. What is the best management for this patient?

(A) Temporary transcutaneous pacing
(B) Mapping with ablation therapy
(C) Implantable cardiac defibrillator (ICD) placement
(D) Electrophysiologic studies are required as soon as possible
(E) No further intervention

Answer:

(E) No further intervention

Explanation:

Long-term studies have shown that patients with premature ventricular contractions (PVCs) or nonsustained ventricular tachycardia without structural heart disease have a benign, long-term prognosis and do not require special intervention. This patient has no symptoms, no history of coronary disease, and a normally functioning heart as shown on echocardiogram. Those patients with ischemic heart disease have an increased risk of sudden death when in the presence of this type of arrhythmia. Another factor that greatly influences prognosis is a poor left ventricular function (ejection faction of <40%), in which case electrophysiological studies and, perhaps, an ICD placement is indicated. When the patient is otherwise healthy, asymptomatic, and has a normal ventricle on echocardiogram, do not offer treatment for nonsustained VT or PVCs.

Topic:

Cardiology

Record # 18

Question/Fact:

A 40-year-old woman was hospitalized 3 weeks ago for cholecystectomy and placed on antibiotics. During her recovery, she developed severe abdominal pain, which was diffuse and nonradiating and associated with diarrhea and fever. Physical examination was remarkable for diffuse abdominal tenderness. Her WBC count was found to be 45,000/mm3. On microscopic examination, there were no fecal leukocytes, and the stool was occult-blood negative. Clostridium difficile toxin was found to be positive. She was treated with 500 mg metronidazole orally four times a day for 10 days and was discharged home.

Two weeks later, she returns to the emergency department complaining of fever, abdominal pain, decreased appetite, and at least 20 watery bowel movements daily. On physical examination, she is febrile to 38 C and mildly tachycardic but has normal blood pressure. She is weak, with dry oral mucosa and sunken eyes. Her lungs are clear to auscultation, and no heart murmurs are heard. Her abdomen is diffusely tender with hyperactive bowel sounds, and stool is guaiac-negative. Extremities show no edema or cyanosis. What is the next best step in the management of this patient?

(A) Admit to the hospital with bowel rest and 500 mg metronidazole orally four times a day for 10 days
(B) Admit to the hospital with bowel rest and 125 mg vancomycin orally four times a day for 10 days
(C) Admit to the hospital with bowel rest and treat with 500 mg IV metronidazole every six hours for 10 days
(D) Admit to hospital with bowel rest and treat with 125 mg vancomycin IV every six hours for 10 days
(E) She can safely be sent home because the symptoms will resolve without further treatment

Answer:

(A) Admit to the hospital with bowel rest and 500 mg metronidazole orally four times a day for 10 days

Explanation:

Retreatment with metronidazole is the most effective treatment. Resistance is rare; therefore, vancomycin is rarely needed. Oral metronidazole is more effective than intravenous use. Tapering with alternative day dosing for an additional 2 weeks could also be considered.

Topic:

Gastroenterology

Record # 19

Question/Fact:

A 54-year-old man from Thailand presents to your office complaining of occasional shortness of breath. He claims that the shortness of breath occurs shortly after having intercourse with his wife. He denies any chest pain, nausea, vomiting, or diaphoresis. He also denies hemoptysis or palpitations. He claims that be has been married for 30 years and he has noticed this shortness of breath increasing in frequency over the past year. He denies any medical history and denies taking any medications. On examination, the patient is noted to have a diastolic murmur, best heard in the left lateral recumbent position. The remainder of the exam is unremarkable. The patient is sent for transthoracic echocardiogram, which reveals a mitral area of 1.8 cm2 with a transmitral gradient of 3 mm Hg. No left atrial enlargement or thrombus is seen. What is the next best step in the management of this patient?

(A) Transesophageal echocardiogram (TEE)
(B) Cardiac catheterization
(C) Echo-stress test
(D) Start the patient on atenolol 25 mg daily
(E) Schedule patient for valvulotomy

Answer:

(C) Echo-stress test

Explanation:

In a patient who is minimally symptomatic with a mitral valve area of greater than 1.5 cm2, the best management would be to assess the patient's symptoms while performing exercise. This is done to measure the pulmonary artery pressure and transmitral gradient during a stress echocardiogram test during either bicycle or treadmill exercise. One can also confirm the effect of exercise by actually seeing the effects of exercise while performing a right heart catheterization. If the patient does not have a pulmonary artery pressure of >60 mm Hg, or a gradient of >15 mm Hg across the mitral valve, the patient can be followed up yearly for changes in symptoms and valve area.

Cardiac catheterization is not needed to confirm the diagnosis of mitral stenosis. The role of cardiac catheterization comes into play when a patient is scheduled for mitral valve surgery to evaluate for underlying coronary artery disease and a more exact measurement of the valve area and gradient. The role of transesophageal echocardiogram (TEE) in mitral stenosis would be to evaluate for a left atrial thrombus in a patient who presents with new-onset atrial fibrillation in the setting of mitral stenosis. TEE is also crucial for evaluation for a left atrial thrombus prior to commissurotomy because any evidence of a left atrial thrombus is a contraindication a commissurotomy. If the patient has no symptoms and the echocardiogram shows only mild stenosis, the patient can be sent home and followed up yearly for changes in valve area and symptoms.

If the patient is not a candidate for valvulotomy because of mild symptoms and mild stenosis, he can be started on a beta-blocker after appropriate evaluation with a stress echocardiogram. In patients with mitral stenosis, the increased heart rate -- as this patient experienced during intercourse -- results in a decreased diastolic filling period, thereby increasing the transmitral gradient and increasing the backflow of blood into the lungs.

Topic:

Cardiology

Record # 20

Question/Fact:

A 67-year-old malnourished man with a history of heavy alcohol abuse for the last 15 years was brought to the emergency department unresponsive. He becomes pulseless, and the monitor reveals ventricular tachycardia (VT) with a rate of 160/min. Cardiopulmonary resuscitation is started, the patient receives three consecutive shocks, and epinephrine is administered, followed by one more shock, which returns him to sinus rhythm. Now his pulse is 136/min, and his blood pressure is 125/70 mm Hg. Two minutes later, the patient is loses his pulse and has a recurrence of VT. After three shocks, the VT persists. Which of the following medications would you give him?

(A) Bretylium
(B) Diltiazem
(C) Quinidine
(D) Magnesium sulfate
(E) Dofetilide

Answer:

(D) Magnesium sulfate

Explanation:

Chronically malnourished people and alcoholics usually have low levels of magnesium. Hypomagnesemia predisposes patients to developing ventricular dysrhythmias, which may be refractory to antiarrhythmic therapy. Magnesium should be given to any patient with a persistent ventricular arrhythmia. Magnesium is most effective for the treatment of torsades de pointes. This man's VT, described as polymorphic, may also be torsades. Calcium-channel blockers may worsen wide complex tachycardias. Quinidine and dofetilide are sometimes used in patients with supraventricular arrhythmias to convert them to sinus rhythm. Dofetilide actually causes ventricular tachycardia; it is one of its most common adverse effects.

Topic:

Cardiology

Record # 21

Question/Fact:

A 70-year-old man with chronic stable angina comes to the emergency department describing being awakened by severe precordial discomfort radiating to the left arm. The pain was not relieved with sublingual nitroglycerin tablets and was associated with dyspnea and diaphoresis. His past history is significant for poorly controlled hypertension. His blood pressure in the emergency department is 195/110 mm Hg. He also had a nonhemorrhagic stroke last year. The ECG shows 2 mm of ST-segment elevation in V1-V4 and ST-segment depression in the inferior leads. Which of the following is true about the patient's condition?

(A) This patient should not be considered a candidate for angioplasty
(B) Thrombolytic therapy doesn't reduce the risk of in-hospital death from infarction
(C) Thrombolytic therapy should be started as soon as possible for this patient
(D) Tissue plasminogen activator (t-PA) is more effective than streptokinase at restoring full perfusion (TIMI grade 3 coronary flow)
(E) Routine angiography is recommended in all patients after thrombolysis

Answer:

(D) Tissue plasminogen activator (t-PA) is more effective than streptokinase at restoring full perfusion (TIMI grade 3 coronary flow)

Explanation:

When ST-segment elevation in at least two contiguous leads of at least 1 mm is present, a patient should be considered a candidate for reperfusion therapy with thrombolytic agents or percutaneous transluminal coronary angioplasty. Thrombolytic therapy can reduce the relative risk of in-hospital death by up to 50% when administered within the first hour of the onset of symptoms of an acute infarction. When appropriately used, thrombolytic therapy appears to reduce infarct size, limit ventricular dysfunction, and reduces the incidence of serious complications, such as a septal rupture, cardiogenic shock, and malignant ventricular arrhythmias.

Clear contraindications to the use of thrombolytic agents include a history of cerebrovascular hemorrhage at any time, a nonhemorrhagic stroke within the past year, a systolic pressure of >180 mm Hg or a diastolic pressure of >110 mm Hg, suspicion of aortic dissection, or active internal bleeding (excluding menses).

T-PA is more effective than streptokinase at restoring full perfusion, i.e., TIMI grade 3 coronary flow. When assessed angiographically, flow in the culprit coronary artery is described by a simple qualitative scale called the TIMI grading system: Grade 0 indicates complete occlusion of the infarct related artery; grade 1 indicates some penetration of the contrast material beyond the point of obstruction but without perfusion of the distal coronary bed; grade 2 indicates perfusion of the entire infarct vessel into the distal bed but with flow that is delayed compared with that of a normal artery; and grade 3 indicates full perfusion of the intact vessel with normal flow.

Routine angiography after thrombolysis is not recommended. After thrombolytic therapy, cardiac catheterization and coronary angiography should be carried out if there is evidence of failure of reperfusion, such as persistent chest pain or progression to congestive failure. Angiography and angioplasty should also be considered in the management of coronary artery re-occlusion as determined by re-elevation of the ST segments or recurrent chest pain later in the hospitalization or a positive exercise stress test before discharge.

Topic:

Cardiology

Record # 22

Question/Fact:

A 56-year-old man presents to your office complaining of generalized weakness for the past few days. He also has neck pain. His wife finds that he has appeared more anxious and irritable. He denies fever, chills, or recent travel outside the United States. Review of symptoms is positive for a recent upper respiratory infection 1 month ago and occasional palpitations. Physical examination reveals a small-built, diaphoretic male in no acute distress. His temperature is 99.8 F, pulse is 90/min, and blood pressure is 142/90 mm Hg. Palpation of the neck reveals mild enlargement of the right superior pole of the thyroid. The gland is extremely tender, and his sedimentation rate is increased. There are also increased T4 and T3 levels. The thyroid-stimulating hormone (TSH) level is decreased. There is decreased radioactive-iodine uptake. What would be your next step in the management of this patient?

(A) Biopsy of the thyroid
(B) Propylthiouracil
(C) Prednisone
(D) Ultrasound of the thyroid
(E) Aspirin

Answer:

(E) Aspirin

Explanation:

This patient most likely has subacute thyroiditis. He has symptoms of hyperthyroidism, such as weakness, irritability, palpitations, and a borderline elevation in blood pressure -- all relatively mild symptoms. His condition occurred after a recent viral infection. The clue to the diagnosis of subacute thyroiditis is the neck pain and tender thyroid gland. He has a high thyroid-hormone level but a decreased radioactive-iodine uptake, indicating a leakage of hormone from a damaged gland, not simply an overly active gland, as in Graves' disease. (Graves' disease would give you an elevated thyroid-hormone level, but the iodine uptake would be increased and the gland would not be tender or painful.) A high sedimentation rate is characteristic of subacute thyroiditis. Most cases will resolve on their own. They never need propylthiouracil because this is not a hyperactively functioning gland. Most cases with only mild symptoms only need treatment with aspirin or other NSAIDs to relieve the pain, tenderness, and inflammation. Those who do not respond should be treated with prednisone if the clinical manifestations are severe or persist despite therapy with aspirin. Symptoms of hyperthyroidism can be managed with beta-blockers. The biopsy is unnecessary, and an ultrasound is used to evaluate mass lesions.

Topic:

Endocrinology

Record # 23

Question/Fact:

A 68-year-old woman presents to your office complaining of feeling tired for the past 3 months. Before that, she had been in her usual state of health. She also noticed that she has difficulty moving. She claims that she was afraid to come to the doctor sooner because she did not want to hear the words, "You're getting older!" She has no past medical history and uses no medications. Her blood pressure is 120/70 mm Hg, and her heart rate is 56/min. The neck examination is normal. Laboratory studies reveal: sodium 130 mEq/L, potassium 3.6 mEq/L, BUN 11 mg/dL, creatinine 0.9 mg/dL, cholesterol 230 mg/dL, HDL 35 mg/dL, triglycerides 200 mg/dL, hematocrit 32%, and mean corpuscular volume 97 μm3. Her thyroid-stimulating hormone (TSH) level is 20.2 mU/L (normal 0.4-5.0 mU/L), and free T4 is 1.4 ng/dL (normal 0.4-5.0 ng/dL). What is the next best step in the management of this patient?

(A) Repeat TSH and free T4 levels in 1 month
(B) Check for thyroid antibodies
(C) Start the patient on methimazole
(D) Start the patient on levothyroxine
(E) Initiate an anemia evaluation

Answer:

(D) Start the patient on levothyroxine

Explanation:

A low normal thyroxin (free T4) level and a moderately elevated TSH define subclinical hypothyroidism. These patients are usually asymptomatic; however, if the patient does have symptoms, it is necessary to initiate treatment. Subclinical hypothyroidism is likely to progress to overt hypothyroidism if the TSH exceeds 10 mU/L or if there are thyroid antibodies present in high titers. All metabolic abnormalities such as hyponatremia, hypercholesterolemia, and anemia will all likely resolve with therapy.

Topic:

Endocrinology

Record # 24

Question/Fact:

A 68-year-old man is brought to the hospital by his family after an episode loss of consciousness episode at home. At the time of the event, he was sitting in a chair and watching a movie. He is unable to provide a better description, but according to his wife, he fell to the floor, very pale and sweaty, and regained consciousness in 3 to 4 minutes. After the event, the patient felt lightheaded and weak. He and his wife deny convulsive movements, enuresis, or encopresis. He has had three similar episodes of loss of consciousness over the past two years. His past medical history is significant for multiple sclerosis, hypertension with a usual blood pressure of 160/90 mm Hg, and Parkinson's disease. His medications include Sinemet, baclofen, multivitamins, and lisinopril. The patient is usually mobile only via wheelchair and is confined to bed most of the time.

On physical examination, his heart rate is 88/min. His blood pressure is 140/80 mm Hg in the supine position. When he is sitting up, his pressure drops to 90/66 mm Hg. He has a quadriparesis with muscular strength in the arms of 3/5 and limited movement of the lower extremities. There are no murmurs and no carotid artery bruits. The EKG reveals a normal sinus rhythm with rate of 78/min, with suggestions of left ventricular (LV) hypertrophy and a Mobitz I AV block. The echocardiogram has an ejection fraction of 45%, with LV hypertrophy and mild-to-moderate regurgitation of the mitral, tricuspid, and aortic valves. The Holter monitor is normal.

What would you recommend to prevent future episodes of loss of consciousness in this patient?

(A) Discontinue Sinemet
(B) Midodrine
(C) Elastic support hose
(D) Permanent pacemaker implantation
(E) Increased water and sodium intake

Answer:

(B) Midodrine

Explanation:

This patient presents with orthostatic syncope, most likely caused by dysautonomic syndrome. The diagnosis of orthostatic syncope is supported by the presence of postural hypotension. Normally, when one stands, the systolic blood pressure drops only 5 to 15 mm Hg, and the diastolic blood pressure rises a little. Both of these changes should resolve in <1 minute. In orthostasis, the decrease in blood pressure is greater than 20 mm Hg, and the diastolic blood pressure frequently drops by more than 10 mm Hg. Common etiologies include volume depletion, medications, diabetes, and alcohol intake. Dysautonomic syndromes causing orthostatic hypotension are divided into two categories: primary and secondary. Primary autonomic failure is idiopathic and includes pure autonomic failure (Bradbury-Eggleston syndrome) and multiple system atrophy (Shy-Drager syndrome). Secondary causes include amyloidosis, tabes dorsalis, multiple sclerosis, spinal tumors, and familial dysautonomia. Treatment options include elastic support stockings and increased salt and water intake. These can be dangerous for some patients with decreased systolic function. Compressive garments are of questionable value. Fludrocortisone, ephedrine sulfate, and midodrine are indicated in severe cases. Midodrine is an alpha-1-receptor agonist and is used to treat orthostatic hypotension of moderate severity. Midodrine causes arteriolar and venous constriction without central nervous system or cardiac stimulation.

Sinemet may exacerbate orthostatic syncope, but there is no reason why this chronic medication should be causing syncope now. ACE inhibitors also may cause low blood pressure, but it should be low all the time, not just in an intermittent, episodic fashion. Pacemaker insertion is indicated in the presence of severe arrhythmias, symptomatic bradyarrhythmias, and severe AV block, all of which are not present in this patient.

Topic:

Cardiology

Record # 25

Question/Fact:

What is the appropriate mode of colorectal cancer screening for the following case?

A 77-year-old man who had a colonoscopy last month and was found to have a 1-cm tubulovillous adenoma completely excised.

(A) Colonoscopy now and every 10 years
(B) Flexible sigmoidoscopy now and every 5 years
(C) Colonoscopy at age 50 and every 10 years
(D) Colonoscopy now and every 10 years
(E) Stool occult cards every year; colonoscopy if positive
(F) Colonoscopy at age 40 and every 5 years
(G) Colonoscopy in 3 years
(H) Colonoscopy in 1 year
(I) Colonoscopy every 1 to 2 years

Answer:

(G) Colonoscopy in 3 years

Explanation:

Colonoscopy is the preferred method of screening for colon cancer. Average-risk persons should undergo colonoscopy at age 50, and if normal, every 10 years. If a polyp is found, the colonoscopy should be repeated after 3 years. When there is a family history of colon cancer, screening should begin at age 40 or ten years prior to the age of the family member. The earlier date is respected. Follow-up examinations for persons with family histories of colon cancer should occur at 5-year intervals. When there are multiple family members, screening colonoscopy should be performed at age 25 and every 1 to 2 years (characteristic of persons with hereditary nonpolyposis colorectal cancer (Lynch syndrome). Colonoscopy is recommended 1 year after a hemicolectomy for colon cancer to verify the absence of recurrence and the presence of new lesions.

Topic:

Gastroenterology

Record # 26

Question/Fact:

A 56-year-old woman with a past medical history significant for coronary artery disease, hypertension, and peripheral vascular disease was brought to the emergency room with hypotension and severe abdominal pain. On angiography, the patient was noted to have an abdominal aorta 7 cm in width. The patient underwent surgery for six hours to repair the aneurysm. After the procedure, while in the surgical intensive care unit, one notices that her urine output is minimal and that her serum creatinine has risen from 1.0 to 3.2 mg/dL over the past 2 days. Her current medications are the same as what she has always used at home: lisinopril, aspirin, metoprolol, and atorvastatin. The patient denies any allergies. Physical examination reveals a bluish discoloration of the right great toe. Laboratory studies reveal the following:

Sodium 142 mEq/L; potassium 5.1 mEq/L; bicarbonate 25 mEq/L; BUN 24 mg/dL; creatinine 3.2 mg/dL. CBC shows 10% eosinophils. Urinalysis reveals specific gravity as 1.010, a pH of 6.5, and the presence of white cells. There are no red cells in the urine.

Which of the following is the most accurate diagnosis for this patient?

(A) Allergic interstitial nephritis
(B) Renal vein thrombosis
(C) Atheroembolism
(D) Contrast-induced azotemia
(E) Aspirin-induced renal failure

Answer:

(C) Atheroembolism

Explanation:

In a patient with obvious eosinophilia, one has to think of two main causes: atheroembolism and allergic interstitial nephritis. In a patient with allergic interstitial nephritis, one would also expect a history of recent new drug ingestion, fever, and rash or arthralgias. With the history of abdominal aorta repair and manipulation of the aorta, the clinical picture points to atheroembolism. The bluish discoloration of the toe implies an embolus to the toe.

The diagnosis is unlikely to be renal vein thrombosis with no history of pulmonary embolism, flank pain, or nephrotic syndrome, and with no evidence of hematuria on urinalysis. Similarly, it is unlikely to be aspirin or nephrotoxin-induced azotemia because the medications were not altered.

Contrast-induced renal failure gives an elevated BUN and creatinine with a >15:1 ratio, similar to what you would find with prerenal azotemia. This is because of the intense vasoconstriction of the afferent arteriole. In addition, contrast-induced renal failure gives a high urine specific gravity.

Topic:

Nephrology

Record # 27

Question/Fact:

A 25-year-old woman comes for a second opinion concerning abnormal test results. One month ago, she had an episode of abdominal pain associated with nausea, vomiting, and diarrhea, lasting for one day after she had dinner in a restaurant. Laboratory tests done at that time showed a persistently elevated amylase level. The rest of laboratory tests, as well as abdominal ultrasound and CT scan, demonstrated no abnormalities. The patient denies a family history of pancreatitis, diabetes mellitus, or any malignancies. She denies smoking, drinking alcohol, and does not take any medications at home. She does not have any complaints at present time, and physical examination is unremarkable. You order additional tests and receive following results: Serum amylase is 600 U/L (normal <90 U/L), and lipase is 65 U/L. Liver function tests are within normal limits. Urine amylase is 2.4 U/h (normal 6.5-48.1 U/h). BUN is 18 mg/dL, and creatinine is 0.9 mg/dL. The chest x-ray is negative, the mammogram is negative, and the pelvic sonogram is also negative. What is your next step?

(A) ERCP
(B) Isoamylase level
(C) Endoscopic ultrasonography
(D) Reassurance
(E) Repeat CT scan in one month

Answer:

(D) Reassurance

Explanation:

This patient presents with macroamylasemia, a condition associated with asymptomatic elevation of the serum amylase level. Usually, this is an accidental finding that is not related to disease of the pancreas or other organs. In macroamylasemia, amylase circulates in the blood in a polymer form too large to be excreted by the kidney. Laboratory tests, as in this patent's case, demonstrate an elevated serum amylase level, a low urinary amylase value, and a Cam/Ccr ratio of less than 1. The diagnosis of macroamylasemia does not require any further work-up, so reassurance is the best answer.

The prevalence of macroamylasemia is 1.5% of the nonalcoholic, general adult, hospital population. Macrolipasemia has now been documented in a few cases of cirrhosis or non-Hodgkin's lymphoma. The pancreas appears normal on ultrasound and CT scan. Lipase was shown to be complexed with immunoglobulin A. Thus, the possibility of both macroamylasemia and macrolipasemia should be considered in the elevation of these enzymes. In this patient, we don't have any clinical evidence of biliary obstruction or pancreatic malignancy, so ERCP and endoscopic ultrasonography are not indicated at this time. Isoenzymes levels are more sensitive than total amylase and more useful in identification of nonpancreatic causes of hyperamylasemia. Isoenzymes fall into two categories: those arising from pancreas (P isoamylases), and those arising from nonpancreatic sources (S isoamylases). In normal serum, 35-45% of amylase is of pancreatic origin. In the case of our patient, we already know that amylase excretion by kidneys is decreased, and measurement of isoamylases will not give more information in support of the suspected diagnosis. Repeating the CT scan of the abdomen in one month is not likely to be helpful.

Topic:

Gastroenterology

Record # 28

Question/Fact:

A 37-year-old woman with no significant past medical history presents to the emergency department complaining of midepigastric pain radiating to her back since early in the morning. The pain began acutely after eating breakfast and has been gradually worsening. She denies use of tobacco products or any recent travel. Both she and her husband have HIV, and her CD4 count is 560. Her medications include zidovudine, didanosine, and indinavir, which she has been on for the past five years. She takes oral contraceptive pills but occasionally forgets to take them. On review of systems, the patient denies chest pain, shortness of breath, melena, diarrhea, or constipation. She claims that for about two weeks she has been feeling nauseous in the morning with occasional episodes of vomiting.

Vital signs are: temperature 99.9 F, respiratory rate 20/min, blood pressure 100/60 mm Hg, and heart rate 110/min. Examination of head, eyes, ears, nose, and throat reveals no scleral icterus. There are no heart murmurs, and her lungs are clear. Examination of the abdomen shows bowel sounds, tenderness in the midepigastric area on palpation, but no Cullen's or Grey-Turner's signs. Rectal is heme-negative, and no edema is seen in the extremities. Laboratory studies show: WBC 17,000/mm3, hemoglobin 10.2 g/dL, hematocrit 31%, platelets 425,000/mm3, and electrolytes are normal. Amylase is 250 U/L (normal <90 U/L), liver function tests are normal, and urine analysis is unremarkable, except that the urine pregnancy test is positive. What is the most likely cause for this patient's symptoms?

(A) Chronic alcohol use
(B) Ectopic pregnancy
(C) Blunt trauma
(D) Didanosine
(E) Esophageal rupture

Answer:

(B) Ectopic pregnancy

Explanation:

These symptoms are most likely related to an ectopic pregnancy. Although all the given answer choices can cause a direct rise in amylase or an indirect rise of amylase by causing a picture of acute pancreatitis, the patient's history and laboratory results point in the direction of an ectopic pregnancy. An amylase level less than three times the upper limit of normal is often not related to acute pancreatitis. Amylase is elevated in an ectopic pregnancy from the release of amylase by the fallopian tubes. Other diagnostic clues that point to the patient's ectopic pregnancy are a positive urine pregnancy test and morning nausea and vomiting.

Topic:

Gastroenterology

Record # 29

Question/Fact:

A 71-year-old man is admitted from the emergency department to telemetry for chest pain. He had a triple bypass two years ago but continued to experience occasional chest pain on exertion. Recently, the patient has begun having chest pain at rest. This time, the chest pain started approximately three hours ago and was slightly relieved with sublingual nitroglycerin. He usually takes metoprolol, aspirin, lisinopril, atorvastatin, and a nitroglycerin patch. All of them are continued in the hospital.

Upon arrival to the floor, his vital signs are: temperature 99.2 F, blood pressure 128/62 mm Hg, pulse 56/min, and respirations 16/min. The physical examination is unremarkable. His first set of cardiac enzymes and the EKG are normal. The nurse calls you a half-hour after you saw the patient to tell you that he is complaining of chest pain. You perform an EKG, and it reveals 3-mm of ST depression in the lateral leads, which was not seen on the previous EKG this evening. Which of the following medications should be administered to this patient at this time?

(A) Heparin alone
(B) Clopidogrel (Plavix)
(C) Heparin and coumadin
(D) Tirofiban (Aggrastat)
(E) Tirofiban and heparin

Answer:

(E) Tirofiban and heparin

Explanation:

The combination of heparin plus a glycoprotein IIB/IIIA inhibitor has been shown to have a greater efficacy in lowering the incidence of ischemic events and reducing morbidity and mortality in patients with acute coronary syndromes compared with the use of heparin alone. The currently available glycoprotein IIB/IIIA (GP IIB/IIIA) inhibitors are tirofiban, abciximab, and eptifibitide. Clopidogrel (Plavix) is an antiplatelet agent mainly used as a substitute for aspirin in those who cannot tolerate aspirin because of allergy. Clopidogrel is also used for patients who have had angioplasty and intracoronary stent placement. Ticlopidine is another medication that can be used for the same indications. Ticlopidine is now used far less frequently because of the high rate of developing neutropenia and thrombotic thrombocytopenic purpura (TTP). Warfarin (coumadin) has not been shown to be effective in acute coronary syndromes and takes a much longer time to become therapeutic.

Topic:

Cardiology

Record # 30

Question/Fact:

A young woman from Africa is visiting the United States and comes to the emergency department complaining of a headache and vomiting for the last two days. Family members have also noted a change in mental status and lethargy. She has had no recent contact with animals. Physical examination reveals nuchal rigidity. The white cell count is elevated, and the chest x-ray shows small, cavitary, apical lesions and hilar adenopathy. A lumbar puncture shows an elevated opening pressure, clear cerebrospinal fluid, and an elevated white count of 187/hpf, which are mostly lymphocytes. There is a markedly elevated protein level. Gram's stain and acid-fast staining of the cerebral spinal fluid are negative. What is the next step?

(A) Await the results of the acid-fast culture
(B) Await adenosine deaminase levels
(C) Start isoniazid, rifampin, pyrazinamide, and ethambutal
(D) Start isoniazid, rifampin, pyrazinamide, ethambutol, and steroids
(E) Head CT scanning

Answer:

(D) Start isoniazid, rifampin, pyrazinamide, ethambutol, and steroids

Explanation:

The patient most likely has tuberculous meningitis. The mildly elevated cerebral spinal fluid (CSF) lymphocyte count by itself is nonspecific and would only reliably exclude acute bacterial meningitis, which should be characterized by a markedly elevated neutrophil count in the CSF. The markedly elevated protein level is highly suggestive of tuberculous meningitis. This patient also has a cavitary lung lesion at the apex and is from Africa, which also makes the diagnosis of tuberculous meningitis much more likely. You can't wait for the 4 to 6 weeks it would take to obtain culture results in a patient as ill as the one described here. Adenosine deaminase is sometimes elevated in the CSF in patients with tubercular meningitis; however, it cannot be considered a fully standardized test as of yet. You should add steroids to the initial four-drug regimen in patients with tubercular meningitis and pericarditis. Although the steroids do not decrease mortality, they do diminish the likelihood of developing permanent neurological deficits.

Topic:

Pulmonary

Record # 31

Question/Fact:

A 35-year-old man presents to the clinic with bruising and several episodes of epistaxis that occurred a week ago. He states that in the past month he has not been feeling well. It started with severe headaches and a cold with fever of 102 F. He hasn't completely recovered, remaining weak and tired. In addition, now he "started bleeding for no apparent reason." The patient uses no medications. He has no history of transfusions in the past or any bleeding disorders in the family.

His medical history is significant for a hepatitis C infection diagnosed 5 years ago and a recent episode of bacterial gastroenteritis. On physical examination, the patient is slim with pale conjunctiva. Petechiae are present on his legs. Pulse is 85/min, blood pressure is 115/70 mm Hg, and temperature is 100 F. Abdominal examination reveals a slightly enlarged liver with mild tenderness in the right upper quadrant, but no splenomegaly. Neurologic examination reveals no focal deficits.

Laboratory studies show the following:

WBC 5,000/mm3; hematocrit 35%; platelets 30,000/mm3; MCV 90 µm3; BUN 19 mg/dL; creatinine 1.0 mg/dL; LDH 190 U/L; AST 45 U/L; ALT 50 U/L; direct bilirubin 0.2 mg/dL; indirect bilirubin 0.9 mg/dL; PT 13 seconds; PTT 30 seconds.

Peripheral blood smear shows no white or red cell abnormalities, but occasional megathrombocytes are seen. Head CT without contrast shows no cerebrovascular disease or lesions.

What is the best initial management of this patient?

(A) Intravenous immunoglobulins
(B) Prednisone
(C) Plasmapheresis
(D) Fresh frozen plasma
(E) Platelet transfusion

Answer:

(B) Prednisone

Explanation:

This patient presents with symptoms of mucosal bleeding (epistaxis, gum bleeding, and petechiae). Petechiae are seen almost exclusively in conditions of thrombocytopenia, as confirmed in this patient by the low platelet count of 30,000/mm3.

Thrombocytopenia may stem from failure of platelet production, as seen in leukemia, aplastic anemia, or myelodysplastic syndrome. Increased platelet destruction occurs with ITP, TTP, hemolytic uremic syndrome (HUS), or disseminated intravascular coagulation. Increased platelet sequestration happens with an enlarged spleen. Dilution of platelets, lowering the count, occurs with massive blood transfusions.

The normal smear, except for large platelets, points in the direction of increased platelet destruction. Like reticulocytes, newly formed platelets are larger than older platelets. TTP and HUS would show red-blood-cell fragmentation, whereas myelodysplastic syndrome would exhibit white cell abnormalities.

This patient has no history of transfusion. Aspirin by itself rarely causes significant bleeding, but it may unmask bleeding disorders, such as mild von Willebrand's disease or mild thrombocytopenia.

The patient's presentation is consistent with ITP, the hallmark of which is isolated thrombocytopenia with a normal-sized spleen and megathrombocytes on peripheral smear. PT and PTT are normal in ITP.

Prednisone is the initial treatment for ITP. Plasmapheresis and fresh frozen plasma infusion are the treatments for TTP. TTP is unlikely in this patient because there is no evidence of microangiopathic hemolytic anemia.

Fresh frozen plasma is also a treatment of choice for the coagulopathy of liver disease. Hepatic causes are unlikely in this patient because the PT and PTT are normal. Platelet infusion is given in life-threatening bleeding secondary to low platelet counts most often from production problems. Platelet transfusions are rarely used in the treatment of idiopathic thrombocytopenic purpura because exogenous platelets will survive no better than the patient's own and last for less than a few hours. It should be reserved for cases of life-threatening bleeding in which intravenous immunoglobulins and steroids are ineffective.

Topic:

Hemotology-Oncology

Record # 32

Question/Fact:

A 55-year-old man patient presents to your office complaining of increasing episodes of shortness of breath over the last 2 months. The patient claims he was in his usual state of health until two years ago, when he began to notice lower extremity swelling, which he attributed to being on his feet all day. Then approximately two months ago, he began to notice that he became short of breath episodically while lying down and needed to use more pillows. He also noticed that he had to stop after walking five to six blocks to catch his breath. The patient also claims that on occasion, when he gets up from bed, he feels lightheaded and dizzy for a short while. He denies any past medical history.

Physical examination reveals normal vital signs. Jugulovenous distention is present. There is an S3 and S4 gallop audible and evidence of a holosystolic murmur radiating to the axilla. The point of maximal impulse is at the fifth intercostal space in the midclavicular line. There are bilateral rales, and the abdomen shows ascites and hepatomegaly with edema of the extremities. The chest x-ray shows pulmonary congestion with no evidence of cardiomegaly. The EKG shows low voltage, with left-axis deviation and QS waves in the inferior leads. Echocardiogram reveals increased ventricular wall thickness, decreased left ventricular cavity size, and left atrial dilatation. Also noted is a sparkling granular myocardial texture in the interventricular septum.

What is the best treatment for this patient at this time?

(A) Pericardial stripping
(B) Heart transplantation
(C) Palliative and symptomatic
(D) Calcium-channel blockers
(E) Phlebotomy

Answer:

(C) Palliative and symptomatic

Explanation:

In a patient with restrictive cardiomyopathy secondary to amyloidosis, the goal of the treatment is to treat the congestive symptoms. Heart transplantation is contraindicated because of the early recurrence of amyloidosis in the allograft. Pericardial stripping may be indicated as a treatment in a patient with constrictive pericarditis. Beta-blockers and calcium-channel blockers are relatively contraindicated owing to their selective binding to amyloid fibers. Phlebotomy is indicated if hemochromatosis was the underlying disease. Alkylating agents (such as melphalan) are only useful if the amyloid is secondary to plasma-cell disorders, such as myeloma.

Topic:

Cardiology

Record # 33

Question/Fact:

After being found to have slightly elevated liver function tests (LFTs), a 46-year-old man who is moderately overweight and has diabetes is found to have a positive hepatitis-B surface antigen. However, the hepatitis B e antigen is negative. There are antibodies to the e antigen but not to the surface antigen. The AST is 110 U/L, and the ALT is 88 U/L. The albumin, bilirubin, and alkaline phosphatase levels are normal. Which of the following statements concerning this patient is false?

(A) He is a carrier of hepatitis B
(B) Lamivudine would be ineffective in treating his carrier state
(C) Interferon should be considered only if the e antigen is positive
(D) He is not infectious to other persons because the e antigen is negative

Answer:

(D) He is not infectious to other persons because the e antigen is negative

Explanation:

A person with a positive hepatitis-B surface antigen but a negative e antigen is considered a carrier of hepatitis B. Carriers are infectious and are at some increased risk of liver cancer and cirrhosis (although much less than a person who is e-antigen positive). Interferon and lamivudine are FDA approved for the treatment of chronic hepatitis B but are only effective in patients in whom the e antigen is positive.

Topic:

Gastroenterology

Record # 34

Question/Fact:

A 28-year-old woman returns from a camping trip with her boyfriend. She has a tick attached to her buttocks, and you remove the tick in your office. What is the most appropriate management?

(A) Send the tick for analysis
(B) Doxycycline for two weeks
(C) Amoxicillin for two weeks
(D) Lyme serology
(E) Reassurance

Answer:

(E) Reassurance

Explanation:

You do not have to give specific therapy for an asymptomatic tick bite. The rate of transmission of Lyme disease is not sufficient enough to indicate a need for empiric or prophylactic antibiotic treatment. Because she has no symptoms, there is no point in doing a serologic test for Lyme. You would not treat an asymptomatic tick bite, so even if the antibody test were positive, there would still not be a need for therapy. Lyme serology is very poor in distinguishing between old and new disease. There is no point in sending the tick for analysis. This is never routinely done.

Topic:

Infectious Diseases

Record # 35

Question/Fact:

A 21-year-old college student presents to the emergency department complaining of nausea and abdominal pain for the past day. He tells you that he may have had a "bad stomach flu" and recalls having chills, a sore throat, generalized body aches, and a skin rash for the "last few days." He has also had pain in the knees and ankles. He was most concerned about his urine being dark and reddish brown this morning. He adds that aspirin makes him itchy.

Upon examination, the patient seems mildly distressed from the abdominal pain. He is afebrile, his heart rate is 88 per minute, respiratory rate is 16 per minute, and blood pressure is 140/80 mm Hg. There are palpable, purpuric skin lesions on both lower extremities. The dorsal surfaces of the hands are edematous, and the knee and ankle joints are swollen and painful on palpation. The abdomen is mildly distended, soft and tender only on deep palpation. The stool is brown and guaiac-positive. There is 2+ pedal edema. Laboratory studies reveal:

ANA negative, Na 137 mEq/L, K 3.8 mEq/L, Cl 112 mEq/L, CO2 22 mEq/L, BUN 20 mg/dL, Cr 1.2 mg/dL, serum complement normal, ESR 45 mm/h, ANCA negative. Urinalysis shows specific gravity 1.015 and protein trace with many erythrocytes.

The patient wants to know the treatment and expected outcome. What would you tell him?

(A) He will most likely need hemodialysis within six months.
(B) Corticosteroids should be used for his rash.
(C) Renal transplantation would be the best option.
(D) Spontaneous recovery is likely to occur within several weeks.
(E) Cyclophosphamide should be used for an improved outcome.

Answer:

(D) Spontaneous recovery is likely to occur within several weeks.

Explanation:

The patient has Henoch-Schönlein purpura, which is a form of purpura of unknown cause. This is a vasculitis that most often affects small blood vessels. Hypersensitivity to aspirin has been reported as well. The purpuric lesions are usually located on the lower extremities. Localized areas of edema, especially on the dorsal surfaces of the hands, are reported, as well as joint symptoms in the majority of patients. Abdominal pain secondary to vasculitis of the intestinal tract is often associated with gastrointestinal bleeding. Hematuria is usually related to a reversible renal lesion, although it can progress sometimes to renal insufficiency. The kidney biopsy shows segmental glomerulonephritis with crescents and mesangial deposition of predominantly immunoglobulin (Ig) A and some IgG. The disease is usually self-limited, lasting 1 to 6 weeks, and subsides without sequelae, rarely needing dialysis.

Glucocorticoids and cytotoxic therapy may occasionally be useful in progressive nephritis. Prednisone, ACE inhibitors, and fish oil is sometimes used as a treatment of IgA nephropathy if progressive nephritic or nephrotic syndrome is present. They are also used if poor prognostic signs, such as proteinuria or an increasing creatinine, occur. Although prednisone may lead to a remission of proteinuria and nephritic syndrome, it has not been proven to affect the progression of renal disease. Renal transplantation is a choice for the patients with end-stage renal disease. Cyclophosphamide is a treatment of choice of Wegener's granulomatosis.

Topic:

Nephrology

Record # 36

Question/Fact:

A 25-year-old woman comes to the clinic complaining of increasing fatigue for the past 2 months. She has muscle weakness and frequent muscle cramps. She also noticed that she has to urinate more frequently than usual and has a poor appetite. She takes no medications and doesn't smoke or drink alcohol. The patient is well developed but slim and tired appearing. Her vital signs are normal. The musculoskeletal examination reveals mild bone and muscle tenderness in the lower extremities. She has diminished strength in the lower extremities. Laboratory studies show:

Sodium 140 mEq/L; potassium 2.9 mEq/L; chloride 112 mEq/L; bicarbonate 19 mEq/L; glucose 140 mg/dL; BUN 22 mg/dL; creatinine 1.0 mg/dL; calcium 7.0 mg/dL; albumin 4.0 g/dL.

What is the most accurate diagnostic step in determining the cause of this patient's hypokalemia?

(A) Glucose tolerance test
(B) Vitamin D level
(C) Urine potassium level
(D) Urinary magnesium level
(E) Urinary phosphorus level

Answer:

(C) Urine potassium level

Explanation:

This patient exhibits the signs and symptoms of hypokalemia: fatigue, muscle weakness and pain, polyuria, and diminished motor strength. Three fundamental mechanisms may lead to hypokalemia:

1) Transcellular shift of potassium into cells
2) Reduced potassium intake
3) Excessive potassium loss

Transcellular shift is unlikely in this patient because her glucose is within the normal range, making increased production of insulin unlikely. The bicarbonate level is low, excluding alkalosis. Excessive potassium loss needs to be classified into either renal or extrarenal loss. The urine potassium is the first step. However, the urine potassium concentration may be misleading or simply inadequate when examined by itself because of factors other than potassium homeostasis. The urine potassium concentration may reflect either potassium secretion or aldosterone activity in the tubule. It should, of course, always be done in conjunction with a urinary creatinine. A formula known as the transtubular potassium gradient (TTKG) is designed to take into account factors that might influence a potassium concentration. The TTKG, though, is beyond the scope of this book, and you do not need to learn it to pass your internal medicine boards.

A glucose tolerance test is not indicated because the patient's glucose is within the normal limits. This patient has evidence of Fanconi's syndrome, such as hypocalcemia, metabolic acidosis, and bone tenderness. In this disease, the entire proximal tubule transport function is impaired, resulting in glycosuria, generalized aminoaciduria, proximal RTA, phosphaturia, and uricosuria. There is also an impaired reabsorption of calcium, magnesium, and citrate. As a result of complex disorders of mineral and vitamin D metabolism, the most frequent clinical finding is metabolic bone disease, such as osteomalacia. Other features include polyuria and muscle weakness secondary to potassium depletion, as well as nausea, episodic vomiting, and anorexia.

Vitamin D level measurement would be appropriate in this patient considering her hypocalcemia, bone fractures, and bone tenderness. However, it would not reveal a specific cause of hypokalemia. Magnesium and potassium depletion often go hand in hand, and hypomagnesemia can cause hypokalemia by increasing urinary losses. However, the serum (not urine) magnesium level tests would be appropriate.

The urine phosphorus level would be high in this patient due to Fanconi's syndrome, but it is unrelated to hypokalemia.

Topic:

Nephrology

Record # 37

Question/Fact:

A 19-year-old woman is brought to the emergency department with melena and abnormal vaginal bleeding. She has no past medical history and uses no medications. A platelet count shows 9,000 cells/mm3 with a normal hematocrit and white cell count. The peripheral smear is unremarkable. Chemistries are normal. Which of these therapies is the most important initially?

(A) Intravenous immunoglobulins and steroids
(B) Prednisone
(C) Intravenous dexamethasone
(D) Platelet transfusion
(E) Plasmapheresis

Answer:

(A) Intravenous immunoglobulins and steroids

Explanation:

nerally healthy person with isolated thrombocytopenia. The most likely diagnosis is idiopathic thrombocytopenic purpura (ITP). The patient has life-threatening bleeding with melena. The platelet count is profoundly low. The fastest way to raise the platelet count is with intravenous immunoglobulins (IVIG) or anti-Rh immunoglobulins. Steroids should be used, but as a single agent they would not raise the platelet count as rapidly as the immunoglobulins would.

Plasmapheresis is useless in ITP. Platelet transfusion is usually unhelpful because the platelets are destroyed as soon as they are infused into the patient. Platelet transfusion would only be useful if the immunoglobulins and the steroids did not help.

Topic:

Hemotology-Oncology

Record # 38

Question/Fact:

A 55-year-old woman comes to the clinic after being diagnosed with type 2 diabetes mellitus 5 years prior to this visit. Her last hemoglobin A1c measurement showed an elevated level of 12.1%, despite maximal therapy with glyburide and metformin. She is currently asymptomatic and denies any history of frequent urination. On physical examination, you note a normal blood pressure. Her heart, lungs, and the remainder of the physical examination are within normal limits. What is the next step in the management of this patient?

(A) Add bedtime NPH
(B) Add pioglitazone to her current therapy
(C) Add acarbose to her current therapy
(D) Discontinue all oral medications and begin exclusive insulin therapy

Answer:

(A) Add bedtime NPH

Explanation:

If a patient with type 2 diabetes mellitus has poor glycemia control, despite therapy with two oral hypoglycemics, two options are possible: Add a thiazolidinediones, such as pioglitazone, to the current therapeutic regimen or add bedtime NPH insulin. Insulin, rather than the pioglitazone, should be added in this case because you cannot expect the medication to decrease the hemoglobin A1c to goal. At a maximum dose of thiazolidinediones, the hemoglobin A1c usually falls between 1-2%. Therefore, the only way to reach an appropriate hemoglobin A1c in this patient is to add the bedtime NPH. Bedtime NPH works to lower the hemoglobin A1c by blunting the peak in serum glucose that occurs in the early-morning hours after several hours of fasting.

Topic:

Endocrinology

Record # 39

Question/Fact:

A man is admitted for shortness of breath from a pleural effusion. A thoracentesis demonstrated serosanguinous fluid. The fluid shows a total protein of 4.2 g/dL with a serum protein of 6.2 g/dL, an LDH of 220 mg/dL, with a serum of 300 mg/dL. What is the least likely cause of his pleural effusion?

(A) Congestive heart failure
(B) Malignancy
(C) Pancreatitis
(D) Tuberculosis
(E) Collagen vascular disease

Answer:

(A) Congestive heart failure

Explanation:

Congestive heart failure gives a pleural effusion, which is a transudate. Transudates have low LDH and protein levels in the fluid. Exudates give high protein and LDH levels. Cancer, pancreatitis, infections, and collagen vascular diseases are the most common causes of exudative pleural effusions. The pleural fluid to serum ratio of LDH in transudative effusions is <0.6.

Topic:

Pulmonary

Record # 40

Question/Fact:

A 38-year-old nurse with no significant medical history presents to your office for a routine visit. She offers no complaints, except for occasional muscle aches. She denies chest pain, shortness of breath, abdominal pain, and urinary complaints. She denies alcohol, tobacco, or intravenous drug use. She denies any transfusions or needle sticks. She is currently on birth control pills. Vital signs are: temperature 98.5 F, heart rate 68/min, respirations 14/min, and blood pressure 145/75 mm Hg. Examination of head, eyes, ears, nose, and throat is nonicteric. There are no murmurs, and her lungs are clear. Her abdomen is soft and nontender but shows hepatomegaly. There is no cyanosis, clubbing, or edema of the extremities. Laboratory studies show: WBC 9,000/mm3, hemoglobin 13.7 g/dL, hematocrit 40%, platelets 240,000/mm3, sodium 138 mEq/L, potassium 4.3 mEq/L, BUN 12 mg/dL, creatinine 0.9 mg/dL, albumin 3.9 g/dL, total bilirubin 0.7 mg/dL, direct bilirubin 0.3 mg/dL, AST (SGOT) 180 U/L, ALT (SGPT) 112 U/L, and alkaline phosphatase 768 U/L. Further testing reveals that anti-HCV (ELISA) is negative, anti-hepatitis B surface antibody (HBs) is positive, hepatitis-B surface antigen is negative, ANA is 1:80, antimitochondrial antibody is 1:640, and serum gamma globulin is elevated. Liver biopsy reveals portal mononuclear-cell infiltrate that invades the hepatocyte boundary (limiting plate) surrounding the portal triad and permeates the surrounding lobule. There is minimal evidence of fibrosis. What is the best treatment for this patient at this time?

(A) Prednisone 30 mg daily
(B) Ursodeoxycholic acid 300 mg tid
(C) Recombinant interferon--2a, 5 million units daily
(D) Lamivudine 100 mg daily
(E) Repeat liver function tests and liver biopsy in 3 months

Answer:

(B) Ursodeoxycholic acid 300 mg tid

Explanation:

Primary biliary cirrhosis is characterized by a progressive inflammatory process involving the portal tract, leading to progressive fibrosis and, ultimately, cirrhosis. Ninety-five percent of patients have a positive antimitochondrial antibody. Ursodeoxycholic acid will typically help normalize liver function tests and prevent progression to endstage liver disease.

Topic:

Gastroenterology

Record # 41

Question/Fact:

A 45-year-old white woman presents to the emergency room with complaints of chest pain for the past month. The pain occurs on exertion, without correlation to the amount of exercise, as well as at rest. It lasts for 3 to 5 minutes, then stops by itself. The patient denies radiation of the pain. She states that for the past year, she has experienced episodes of palpitations that she attributed to "nervousness." For the last six months, she also feels slightly more short of breath then usual during her aerobic exercises. Now, with the onset of chest pain, the patient is worried because her mother died of a heart attack at the age of 60 years. The patient's past medical history is significant for hypertension diagnosed two years ago, for which she takes hydrochlorothiazide. She denies tobacco smoking, but during her high school years used cocaine. She drinks alcohol socially and works as a computer programmer. On physical examination, the patient is not in acute distress. Her heart rate is 80/min, with a respiratory rate of 15/min, and a blood pressure of 140/76 mm Hg. The carotid pulse is brisk and bifid. There is a forceful point of the maximal impulse on palpation at the precordium. On auscultation there is a 2/6 nonradiating, harsh, midsystolic murmur along the left sternal border, which increases in intensity when the patient stands up. The EKG shows left axis deviation, left ventricular hypertrophy, and nonspecific ST segment and T-wave abnormalities. The chest x-ray is unremarkable. The first set of cardiac enzymes is negative. What would be the most appropriate initial therapy for this patient?

(A) Beta-blockers
(B) Nitrates
(C) Diuretics
(D) Immediate surgery
(E) Catheter ablation

Answer:

(A) Beta-blockers

Explanation:

Patients with obstructive cardiomyopathy frequently present with complaints of chest pain, which is usually atypical. Syncope may occur after exercise. Arrhythmias are common and may precipitate syncope. The symptoms of cardiac failure are not due to systolic malfunction but occur rather as a result of severely decreased compliance. Beta-blockers should be the initial drug in symptomatic patients. They slow the heart rate, increase left ventricular filling, diminish the velocity of blood flow, and reduce the degree of obstruction. Calcium-channel blockers, especially verapamil, are also effective. Anything that decreases cardiac filling is contraindicated in obstructive cardiomyopathy, including diuretics, nitrates, and volume depletion. Surgery is indicated for patients who do not respond to medical therapy.

Topic:

Cardiology

Record # 42

Question/Fact:

A 45-year-old man comes to the office complaining of shooting pains in his legs for the past two weeks. He describes these pains as transient and agonizing. He also has had urinary incontinence for the last four to six months. He drinks alcohol heavily. On physical examination, his gait is unsteady and wide-based. The unsteadiness is exacerbated by eye closure. The vibration and position sense in his legs is decreased, and his deep-tendon reflexes are diminished. His pupils are small, slightly irregular, poorly reactive to light, and more responsive to accommodation. What is the most likely cause of his problem?

(A) Wernicke's encephalopathy
(B) Holmes-Adie syndrome
(C) Diabetes mellitus
(D) Multiple sclerosis
(E) Tabes dorsalis

Answer:

(E) Tabes dorsalis

Explanation:

This patient presents with manifestations of neurosyphilis and tabes dorsalis. The clinical manifestations of neurosyphilis are divided into acute syphilitic meningitis, cerebrovascular disease, dementia (general paresis), and tabes dorsalis. Tabes dorsalis is a myeloneuropathy that involves the proximal dorsal-root entry zones into dorsal-root ganglia. The classic triad includes lightning pains, sensory ataxia, and urinary disturbance. Signs of neurosyphilis include pupillary abnormalities, lower extremity hyporeflexia, and an abnormal Romberg's sign. The pains are most common in the legs but may involve any part of the body. Early loss of vibration and position sense is characteristic, which is attributed to secondary degeneration of the posterior columns of the spinal cord. This produces a wide-based gait, which is exacerbated by the loss of visual input, known as Romberg's sign. Bladder hypotonia with overflow incontinence results from involvement of sacral, sensory nerve roots. Half of the patients with pupillary abnormalities will have the classic Argyll-Robertson pattern, as in our patient. Other pupillary abnormalities will include unilateral mydriatic pupils with loss of the pupillary light reflex.

The diagnosis is confirmed by abnormalities in the cerebrospinal fluid (CSF), an elevated white cell count and protein level, and a positive VDRL. The VDRL has a poor sensitivity and is only positive in 30 to 60% of patients, but it is extremely specific. Although the CSF FTA can be falsely positive from leakage in from the blood, a negative CSF FTA effectively excludes neurosyphilis. The treatment is high-dose, parenteral penicillin for 10 to 14 days or procaine penicillin 2.4 million units intramuscularly once a day, plus probenecid, for two weeks.

Wernicke's encephalopathy is a complication of chronic alcoholism, which is characterized by ophthalmoplegia, ataxia, and a confusional state. Pupillary abnormalities include anisocoria and sometimes a sluggish reaction to light. The most common ocular symptoms are nystagmus, abducens nerve palsy, and horizontal or combined horizontal-vertical gaze palsy. Holmes-Adie's syndrome is a manifestation of a benign familial disorder that primarily affects young women and is associated with depressed deep-tendon reflexes, segmental anhydrosis, orthostatic hypotension, and pupillary involvement. The involvement is a unilaterally enlarged pupil, which is poorly reactive to light and accommodation. This is due to degeneration of the ciliary ganglion. Diabetes mellitus is unlikely to produce pupillary involvement, and decreased reflexes are unlikely in multiple sclerosis.

Topic:

Neurology

Record # 43

Question/Fact:

A 53-year-old woman comes to the office with two weeks of pain in her wrists, tiredness, and diffuse aches all over her body. The discomfort lasts all day long. She is a secretary but has been unable to do her work for the last couple of days because typing has become too painful. She can't wear her watch anymore because of swelling in both her wrists. Her medical history is significant for chronic hepatitis C, for which she had been started on interferon-alpha and ribavirin seven months ago. She also had atrial fibrillation converted to sinus for which she is taking amiodarone. Physical examination reveals tender, swollen joints of both wrists and slightly diminished flexion. Blood tests show a white count of 7,500/mm3, hematocrit of 33%, and 95,000/mm3 platelets with slightly elevated transaminases. The antihistone antibody and ANA are positive. Which of the following is the most likely cause of her problem?

(A) Amiodarone
(B) Interferon
(C) Rheumatoid arthritis
(D) Systemic lupus erythematosus
(E) Hepatitis C

Answer:

(B) Interferon

Explanation:

This patient most likely has drug-induced SLE. Amiodarone is associated with pulmonary fibrosis, thyroid disorders, and corneal deposits, not musculoskeletal problems. The joint pain of rheumatoid arthritis resolves after 1-2 hours in the morning and is not associated with a positive ANA or antihistone antibody. Hepatitis C gives signs of progressive hepatic insufficiency. Several drugs can cause a lupus-like syndrome, including procainamide, hydralazine, isoniazid, chlorpromazine, D-penicillamine, methyldopa, interferon-alpha, quinidine, and possibly hydantoin. The syndrome is rare with all but procainamide, which gives a positive ANA in 50 to 75% of all cases and hydralazine, which gives a positive ANA in 25 to 30% of all cases. Only a small percentage (10-20%) of those who develop a positive ANA from drugs will develop lupus-like symptoms. When it does occur, there are predominantly systemic complaints and arthralgias. A quarter to a half of these patients also have polyarthritis and pleuropericarditis. Renal and CNS involvement are rare in drug-induced lupus. All patients with drug-induced lupus have a positive ANA, and 95% have antibodies to histones. In idiopathic SLE, 75% have antihistone antibodies. Interferon is associated with thrombocytopenia, anemia, and diffuse myalgias and arthralgias but would not give a positive ANA or antihistone antibody unless there was lupus as well. There is also the fact that the symptoms only developed after the start of the interferon.

Topic:

Rheumatology

Record # 44

Question/Fact:

A 50-year-old woman presents to the primary care clinic for the first time. She denies any complaints and states that she feels well. Her medical history is significant for hepatitis C, hypertension, and a mitral valve replacement, performed 10 years ago and due to rheumatic heart disease. Her medications are coumadin and amlodipine. The patient denies alcohol or tobacco use. Her family history includes noninsulin-dependent diabetes in her father and a myocardial infarction in her mother at the age of 75. On physical examination, the patient is an obese female with a blood pressure of 135/80 mm Hg, heart rate of 65/min, and a respiratory rate of 14/min.

ECG reveals no ST-T changes or Q waves. The initial laboratory work-up is done, and the results are as follows: Fasting glucose 75 mg/dL, cholesterol 260 mg/dL, LDL 180 mg/dL, HDL 45 mg/dL, triglyceride 200 mg/dL, TSH 8.50 mU/L (normal 0.35-6.20 mU/L), Free T4 0.9 nmol/L (normal 0.8-2.7 nmol/L), T3 150 ng/dL (normal 59-174 ng/dL). What is the best management for this patient?

(A) Exercise at least 30 minutes per day and start a diet of <300 mg of cholesterol per day
(B) Exercise at least 30 minutes per day and start a diet of <200 mg of cholesterol per day
(C) Exercise, low-cholesterol diet, and atorvastatin
(D) Exercise, low-cholesterol diet, and gemfibrozil
(E) Exercise, low-cholesterol diet, and levothyroxine

Answer:

(E) Exercise, low-cholesterol diet, and levothyroxine

Explanation:

This patient has hypertension as her only risk factor for coronary artery disease (CAD), in addition to a high-cholesterol level. Mitral valve disease, obesity, and a sedentary lifestyle are not separate risk factors because they operate through other risk factors such as hypertension, hyperlipidemia, and diabetes. A family history of diabetes and CAD in a first-degree female relative 65 years or older are not considered to be risk factors. Diabetes would have to be present in the patient themselves for it to be considered a risk. Premature coronary disease in a relative is defined as being present in a male relative <55 years of age or in a female <65 years of age. Dietary therapy should be initiated and tried for 6 months in patients who have no more than one cardiac risk factor and whose LDL levels exceed 160 mg/dL but are less than 190 mg/dL, which is the case in this patient. Drug therapy with a statin would be used if the LDL were above 190 in a patient like this. Levothyroxine is used in this patient because the TSH is high and hypothyroidism may be contributing to the hyperlipidemia.

It is essential to realize that in addition to the lifestyle and hereditary causes of hyperlipidemia, other concomitant disorders may coexist that may give rise to dyslipidemia. Such secondary causes are hypothyroidism, nephrotic syndrome, chronic liver disease, pregnancy, Cushing's syndrome, cholestasis, and estrogen therapy. This patient has subclinical hypothyroidism indicated by mildly elevated levels of TSH. Even subclinical, mild hypothyroidism may cause hyperlipidemia. Therefore, therapy with small doses of L-thyroxine may significantly improve the cholesterol levels.

The difference between choices A and B is a Step 1 diet in choice A versus a Step 2 diet in choice B. A Step 2 diet is assigned when a Step 1 diet fails to bring the LDL level to <160 within 3 months. Patients with CAD should be put on a Step 2 diet immediately.

Starting atorvastatin or gemfibrozil are incorrect for two reasons. First, this patient, having only mildly elevated levels of LDL and one additional risk factor for CAD, does not meet the criteria for initiating drug therapy at this time. Second, atorvastatin, being hepatotoxic, is contraindicated in patients with active liver disease, such as in this patient with chronic hepatitis C.





Topic:

Cardiology

Record # 45

Question/Fact:

A 32-year-old woman presents with cellulitis of her left index finger. She states that she has also been feeling very tired, has had some dyspnea on exertion over the past few months, and easy bruising over the last month. She has bruises on her upper and lower extremities and cellulitis of her left index finger. She has petechiae on the lower extremities. There is no hepatosplenomegaly or lymphadenopathy. Laboratory studies show: WBC 1,400/mm3, with 40% blasts; hematocrit 24.6%; platelets 36,000/mm3. PT is prolonged, D-dimers are elevated, and fibrinogen is low. The bone marrow biopsy shows 43% blasts with fine cytoplasmic granules, and Auer rods are present. There is a positive reaction with Sudan black.What would be the best treatment for her at this time?

(A) Chlorambucil and fludarabine
(B) Alfa-interferon
(C) All-trans-retinoic acid (ATRA)
(D) Bone-marrow transplantation
(E) Daunorubicin with cytarabine and ATRA

Answer:

(E) Daunorubicin with cytarabine and ATRA

Explanation:

This patient has acute promyelocytic leukemia (FAB M3) based on the bone-marrow findings, which include Auer rods and the positive stain with Sudan black, an elevated PT, low fibrinogen, and elevated D-dimers. This particular subtype is frequently associated with disseminated intravascular coagulation (DIC) induced by thromboplastic material released by the leukemic cells.

All-trans-retinoic acid (ATRA) can result in complete remission in this subtype and is now used as the initial induction treatment. ATRA, however, is not given alone: ATRA is used in combination with the usual therapy of daunorubicin and cytosine arabinoside. ATRA brings the rate of complete remission up from 70-80% to 90%. DIC is best treated with platelets and fresh frozen plasma. Chlorambucil or cyclophosphamide is most effective in the treatment of chronic lymphocytic leukemia (CLL). Interferon was useful for chronic myelogenous leukemia (CML) before the invention of imitinab (Gleevec) and in hairy-cell leukemia before the development of cladribine. Cytarabine and daunorubicin (or idarubicin) is typically used in AML as induction therapy. Bone-marrow transplantation from an HLA-identical sibling donor is effective for both ALL and AML but would not be performed until the disease had been brought into remission with chemotherapy. Substantial risks exist with allogeneic bone marrow transplantation, including graft-versus-host (GVH) disease and opportunistic infections.

Topic:

Hematology-Oncology

Record # 46

Question/Fact:

A 55-year-old woman comes to your office with debilitating generalized weakness and constant sleepiness. She was diagnosed with multiple sclerosis twenty years ago. At present, she is wheelchair-bound but still works as a computer programmer. On physical examination, the patient presents with quadriparesis, which is more prominent in the lower extremities. She has increased muscle tone and mild ataxia, which are more prominent in the legs. The cranial nerve examination reveals bilateral horizontal nystagmus. Currently, she undergoes treatment with interferon beta-1a. For relief of spasticity in the lower extremities, she was recently started on tizanidine in addition to baclofen. She did not demonstrate any improvement with moderate doses of baclofen and could not tolerate an increased dose. She also could not tolerate the addition of diazepam due to increased weakness and sedation. Despite the addition of tizanidine, she still has symptoms of spasticity. Her only laboratory abnormality is a slight increase in liver function tests. What would you advise for management of this patient's spasticity?

(A) Increase the dose of tizanidine
(B) Stop baclofen and continue tizanidine
(C) Switch to intrathecal baclofen
(D) Add diazepam
(E) Taper present medications and start dantrolene

Answer:

(C) Switch to intrathecal baclofen

Explanation:

This patient has spasticity, which is not controlled with oral baclofen and tizanidine. In addition, she has increased sedation with the use of benzodiazepines. She should be managed with intrathecal baclofen. Intrathecal baclofen can control the spasticity without the adverse effects of dantrolene on the liver. Although dantrolene could be used in this patient to control spasticity, the problem is that it has a high frequency of liver toxicity and can be associated with worsening liver-function tests. This patient already has an increase in liver-function tests at baseline. Spasticity in multiple sclerosis can be reduced by the GABA-agonist baclofen. This is usually the drug of choice because of its wide effective dose range. Baclofen therapy should be slowly started to avoid sedation or weakness, and it should not be stopped abruptly, as its withdrawal can cause seizures or a confusional state. If the patient demonstrates nocturnal spasms as a side effect of baclofen, diazepam can be added to potentiate the effect of baclofen. Tizanidine is an alpha-adrenergic agonist and is an alternative to baclofen. Its effect may be accompanied by increased drowsiness and orthostatic hypotension. Tizanidine can be added to baclofen when increasing doses of baclofen cause sedation or weakness. Dantrolene is another drug that can be used for spasticity if the patient does not respond well to baclofen, diazepam, or tizanidine, or cannot tolerate the sedation caused by them. Muscle weakness almost always accompanies dantrolene. This is why dantrolene is generally reserved for nonambulatory patients, such as in the wheelchair-bound patient described in this case. Patients who cannot be managed by any of these medications may benefit from the intrathecal injection of baclofen via a fully implantable infusion pump. Increasing the dose of tizanidine or adding diazepam is incorrect because the patient has already demonstrated that she cannot tolerate the side effects of these medications.

Topic:

Neurology

Record # 47

Question/Fact:

A 60-year-old woman comes to your office complaining of tiredness and fatigue for the past two months. Her major symptom is stiffness of wrists, elbows, and ankles, particularly in the morning and lasting about one hour. She is unable to carry out simple tasks, such as opening a jar and squatting to play with her grandson because her knees cause a great deal of pain. She has used acetaminophen with minimal relief. She states that her mother had the same problem for 10 years. She is unable to flex her wrists beyond 50 degrees without pain. She frowns with pain when you ask her to flex and extend her legs. She has no muscle tenderness or decrease in strength. The patient's labs are within normal limits, except for a hematocrit of 32%, an ESR of 25 mm/h, and a rheumatoid factor of 40 IU/mL (normal <30 IU/mL). There are no significant radiological findings of the hands or wrists. What is the most appropriate therapy for this patient?

(A) Naproxen and hydroxychloroquine
(B) Sulfasalazine, hydroxychloroquine, and methotrexate
(C) Prednisone
(D) Leflunomide
(E) Etanercept

Answer:

(A) Naproxen and hydroxychloroquine

Explanation:

Rheumatoid arthritis is a T-lymphocyte-mediated disorder that results in increased proliferation and inflammation of the synovial membrane. A patient with rheumatoid arthritis must have four out of the seven criteria set for rheumatoid arthritis for at least 6 weeks in order to be certain of the diagnosis:

1. Morning stiffness >1 hour
2. Arthritis of 3 or more joints
3. Arthritis of hand joints
4. Symmetrical arthritis
5. Subcutaneous nodules
6. Positive rheumatoid factor
7. Radiological changes (erosion of joints and demineralization)

This patient has a mild-to-moderate form of rheumatoid arthritis with no radiological changes at this time. This patient should be placed on an NSAID with one disease-modifying anti-rheumatoid arthritis drug (DMARD). The best initial DMARDs are methotrexate, sulfasalazine, or hydroxychloroquine. A baseline eye examination is recommended before the start of hydroxychloroquine because it can cause retinitis. Methotrexate would be used with serious disease such as fever, polyarticular disease, or disease with joint erosions on radiology exam. The patient in this question has no fever, no weight loss, and normal x-rays. Those who are to receive methotrexate should have baseline liver function and renal tests.

Therapy with three DMARDs is indicated for patients who have severe disease with increased morning stiffness, persistent swelling of joints, functional disability, and flexor tenosynovitis. Etanercept and infliximab are anti-tumor necrosis factor agents that are most useful in those progressing despite the use of DMARDs. Leflunamide, azathioprine, cyclosporine, and cyclophosphamide are immunosuppressive agents that have therapeutic effects similar to DMARDs but have more toxicity. They are used when DMARDs have failed. Prednisone would never be used alone in the management of rheumatoid arthritis.

Topic:

Rheumatology

Record # 48

Question/Fact:

A 26-year-old woman presents to the emergency department with progressive dyspnea after a soccer game the night before. Over the past few weeks, the patient admits to wheezing on a daily basis. She has increased the frequency of her inhaled albuterol and triamcinolone to two puffs every two to four hours, with minimal relief of her symptoms. She has never used systemic steroids or had to be intubated in the past. While in the emergency department, her peak flow increases from 150 to 180 L/min after three continuous, nebulized albuterol treatments. She appears distressed. She is sitting up in bed and reluctant to lie down. She is afebrile, with a pulse rate of 110/min and a blood pressure of 150/90 mm Hg. She is audibly wheezing. An arterial blood gas shows: pH 7.50, CO2 30 mm Hg, PaO2 76. What is the best treatment strategy?

(A) A long-acting -agonist
(B) Nebulized 2-agonist and intravenous corticosteroids
(C) 2-nebrulized agonist and oral theophylline
(D) -Agonist metered dose inhaler and cromolyn sodium
(E) Epinephrine-based nebulizer and intubation

Answer:

(B) Nebulized 2-agonist and intravenous corticosteroids

Explanation:

This patient is presenting with signs of a severe asthma exacerbation most likely from exercise. She is tachycardic, hypertensive, and in respiratory distress. In most asthmatics with respiratory decompensation, the pCO2 level is low because of hyperventilation. Respiratory acidosis occurs in more severe cases, secondary to respiratory muscle fatigue. Bedside peak flows are routinely measured in patients with severe asthma for comparison after therapy and to determine the severity of an exacerbation. A peak flow of 30% of predicted or <750 L/min marks severe bronchospasm. In the setting of acute asthma exacerbation, long-acting bronchodilators, mediator inhibitors (such as cromolyn), and theophylline will not help acutely. Cromolyn sodium can be used to prevent asthma symptoms and to improve airway function in patients with mild persistent or exercise-induced asthma. Metered-dose inhalers are more effective on an outpatient basis in chronic management. In cases of acute distress or in patients with decreased coordination, nebulizer treatments are easier to use and more effective. This patient did not respond to inhaled bronchodilators; therefore, systemic corticosteroids and more nebulized inhalers need to be used. She does not need to be intubated yet because there is no respiratory acidosis. Epinephrine-based inhalers are not more useful than are other inhaled beta-agonists.

Topic:

Pulmonary

Record # 49

Question/Fact:

A 38-year-old man known to be HIV positive for the past four years comes to the office for his routine visit. He is well controlled on zidovudine, lamivudine, and abacavir. The medications were started two years ago when the patient was found to have a low CD4 count and a high viral load. He has remained asymptomatic without any opportunistic infections. He was on prophylaxis with Bactrim (trimethoprim/sulfamethoxazole) until recently. This was stopped when his CD4 count rose above 300/μL on his last visit three months ago. His viral load was undetectable at that time, as well as six months prior to that. He received influenza and pneumococcal vaccines a week ago. He appears well and seems to be in no distress. You draw a viral load and CD4 count, and he returns a week later to discuss the results. The new CD4 count is 280/μL, and the viral load is 17,000. He has a hematocrit of 40% with an MCV of 108 μm3. What is the most likely explanation for the increase in his viral load?

(A) Nonadherence with his medications
(B) Influenza and pneumococcal vaccine
(C) Development of resistance
(D) Infection with human herpes virus 8 (HHV8)
(E) Drug interactions

Answer:

(B) Influenza and pneumococcal vaccine

Explanation:

A transient burst of viremia has been demonstrated in HIV-infected individuals following immunization with vaccines for such diseases as influenza, pneumococcal infection, and tetanus. This usually lasts from several days to several weeks. It is important to remember not to check the viral load and CD4 counts within several weeks of administering vaccines of any type. The same is true when a patient has a countercurrent infection of any kind. Even though it may not have anything to do with the HIV infection itself, even a mild viral syndrome or cold can artificially depress the CD4 count and raise the viral load. A good clue that the patient is compliant with his medications is the presence of a mild macrocytosis, which is a benign side effect of zidovudine. It is present in all patients adherent to zidovudine and does not need further investigation or treatment. Human herpes virus 8 (HHV8) is the causative organism for Kaposi's sarcoma. There is no evidence that it causes an acute infection syndrome and should not be associated with any alteration of the CD4 count or viral load. Resistance should not occur in a patient who has had a stable antiretroviral regimen with repeatedly undetectable viral loads. Resistance develops when the virus is reproducing. There is no significant interaction between zidovudine, lamivudine, and abacavir.

Topic:

Infectious Diseases

Record # 50

Question/Fact:

A 56-year-old woman presents to the clinic with complaints of progressive dyspnea for the past three months, which has been worse on exertion, as well as a dry cough. She denies fevers, chills, rhinorrhea, chest pain, palpitations, or weight loss. The patient's medical history is significant for coronary disease and atrial fibrillation, which was diagnosed six months ago and at which time the patient was placed on amiodarone. The other medications include aspirin and propranolol. On physical examination, the patient is mildly tachypneic with a respiratory rate of 22/min, a pulse of 80/min, and a blood pressure of 120/80 mm Hg. Respiratory examination reveals bilateral, fine, expiratory crackles. Cardiovascular examination reveals elevated jugular venous pressure, normal S1 and S2 with a regular rhythm, and an accentuated pulmonic component of S2. Bilateral pitting edema of the lower extremities is noticeable. Chest x-ray detects bilateral, interstitial, reticulonodular infiltrates. What is the next best step in the management of this patient?

(A) Stop amiodarone
(B) Start an ACE inhibitor
(C) Start prednisone
(D) Discontinue digoxin
(E) Start azithromycin

Answer:

(A) Stop amiodarone

Explanation:

This patient exhibits signs and symptoms of interstitial lung disease, such as progressive dyspnea on exertion, dry cough, bilateral crackles, and pulmonary hypertension causing right-sided congestive heart failure. These symptoms started soon after administration of amiodarone therapy. One of the known adverse reactions of amiodarone is diffuse pulmonary injury. Therefore, the most important first step in the management of this patient is removing the precipitating agent, amiodarone.

Starting an ACE inhibitor is an incorrect answer because this patient's dyspnea does not stem from congestive heart failure. Starting prednisone would be an acceptable step in the management of interstitial lung disease; however, removing the offending agent is the most important initial step. Discontinuing propranolol will not help because this patient's shortness of breath does not seem to stem from reactive airway disease. Starting azithromycin would be correct for the treatment of Mycoplasma pneumonia. This patient has no fever: Her cough and infiltrates are unlikely to be the result of the community-acquired pneumonia because these symptoms have been going on for three months. Pneumonia is an unlikely cause of such severe interstitial disease as to cause reticulonodular disease on the chest x-ray.

Topic:

Cardiology

Record # 51

Question/Fact:

A 70-year-old Russian man is brought to your office by his son who states that his father has not been himself since this morning. He believes that he is in Russia. The son states that his father has been fine and that he went on a trip and stayed in small hotels. One week after his return, he had what seemed to be the flu. He was coughing and complained of body aches, headaches, diarrhea, and abdominal pain. The patient had a myocardial infarction five years ago and still smokes cigarettes. His temperature is 102 F, respiratory rate is 32/min, blood pressure is 140/80 mm Hg, and the oxygen saturation is 95% on room air. His chest x-ray reveals scattered patchy infiltrates bilaterally. His sodium is 127 mEq/L, and the transaminases are mildly increased. What is the most sensitive and specific method of confirming the diagnosis?

(A) Blood culture
(B) Urine antigen
(C) Antibody serology
(D) Lumbar puncture
(E) Direct fluorescent antibody on sputum
(F) Culture on blood agar
(G) Gram's stain

Answer:

(B) Urine antigen

Explanation:

This patient most likely has Legionella pneumonia. The clue to this diagnosis is the presence of gastrointestinal symptoms, altered mental status, hyponatremia, and abnormal liver function tests in a person with pneumonia. Legionella is a gram-negative aerobic bacillus that does not grow on routine media and enters the lung through aspiration in older men with lung disease, particularly smokers and those who are immunocompromised. It is mostly found in water tanks and old water conditioners. Patients present with the usual symptoms of pneumonia, as well as some additional atypical symptoms, such as malaise, headache, mental status changes, and gastrointestinal symptoms, such as abdominal pain and diarrhea. The chest x-ray is relatively nonspecific. There can be the usual lobar infiltrates or bilateral patchy disease.

The diagnosis of Legionella is complex because the organism cannot be reliably seen on Gram stain or grown on standard culture media. The most sensitive and specific test overall is culture on a special-buffered, charcoal, yeast-extract media. It does not grow on standard blood agar. Blood culture and lumbar puncture have no utility in the diagnosis. The urine antigen has virtually 100% specificity when it is positive. It has 99% sensitivity for Legionella pneumophila type 1, which makes up about 80% of isolates. Although serum antibody testing and direct fluorescent antibody testing of sputum are very specific as well, their sensitivity on initial presentation is <40%.

Topic:

Pulmonary

Record # 52

Question/Fact:

A 60-year-old man with a history of hypertension presents with chest pain and palpitations that started shortly after an encounter with a would-be assailant. The patient denies ever having had symptoms in the past. Physical examination shows an anxious male with a rapid and irregular pulse. The rest of his physical examination is unremarkable. An EKG shows atrial fibrillation with a rate in the 120s. He is diagnosed with new-onset atrial fibrillation and is started on heparin. Shortly after that, he is electrically cardioverted into sinus rhythm. What would be the most effective medication at this time?

(A) Digoxin
(B) Metoprolol
(C) Amiodarone
(D) Verapamil
(E) Quinidine

Answer:

(C) Amiodarone

Explanation:

Amiodarone, a class III drug, has the lowest incidence of proarrhythmia compared with other antiarrhythmics. It is not as effective in converting atrial fibrillation to sinus rhythm as other medications are, such as ibutilide and dofetilide, among others. It is up to 60% effective in maintaining sinus rhythm for up to one year once the patient has been converted into sinus rhythm by other methods. Digoxin is useful only in rate control. Digoxin does not convert atrial arrhythmias into sinus. If a patient is receiving digoxin to slow atrial fibrillation, and the rhythm converts to sinus, it would have done so anyway.

Class II drugs (beta-blockers) and class IV drugs (calcium-channel blockers) work by slowing atrioventricular nodal conduction and slowing heart rate. They are generally not effective in converting or maintaining sinus rhythm once achieved. Quinidine, a class IA drug, is especially useful in converting atrial fibrillation, but it is a proarrhythmic drug and must be used with caution in left ventricular dysfunction. Quinidine is not as effective as amiodarone.

Topic:

Cardiology

Record # 53

Question/Fact:

A 52-year-old man comes to the office for pain developing over the last several hours in the instep of his right foot. He has a red, swollen great toe. He also has multiple tophi along the helices of both ears, as well as over the extensor surface of his right elbow. He has a history of hypertension. What is the most appropriate management of this patient?

(A) Ibuprofen without further intervention
(B) Ibuprofen followed by long-term allopurinol
(C) Allopurinol
(D) Prednisone
(E) Colchicine

Answer:

(B) Ibuprofen followed by long-term allopurinol

Explanation:

This patient has an acute attack of gout. The best initial therapy of acute gout is with rapidly acting NSAIDs, such as ibuprofen. These drugs have the same efficacy as colchicine but do not have all of the adverse effects of colchicine. Colchicine can lead to diarrhea and abdominal pain in as much as 80% of patients. The NSAID dose may then be tapered over the course of several days. Use of a drug to lower the serum uric acid level to less than 6 mg/dL is indicated in all patients with visible tophi or radiographic evidence of urate deposits or in patients with a history of two or more major attacks of gouty arthritis per year. In these cases, allopurinol is the preferred agent because it reduces urate production by inhibiting xanthine oxidase, the rate-limiting step in de novo purine synthesis. Prednisone is used in cases that are refractory to treatment with NSAIDs or colchicine or for those in whom it is not possible to give these drugs.

Topic:

Rheumatology

Record # 54

Question/Fact:

A 53-year-old woman with diabetes is admitted to the hospital for management of her foot, which has been swelling increasingly for the last several weeks. She has no pain or fever. There is a draining, purulent sinus tract in the center of the ulcer. What is most specific test?

(A) X-ray
(B) MRI
(C) Bone scan
(D) Biopsy
(E) Erythrocyte sedimentation rate (ESR)
(F) Culture of the draining sinus tract

Answer:

(D) Biopsy

Explanation:

The biopsy is the only way of obtaining a specific organism to guide therapy. Although the x-ray and the MRI have a high degree of specificity, they cannot possibly determine the specific organism involved. A bone scan is only useful if it is normal. It is able to exclude osteomyelitis with 95% sensitivity. Nuclear scans cannot determine the specific organism involved. Although a culture of the draining sinus tract will grow an organism, there is no way of being sure that the organism you grow is definitely the organism inside the bone. Culture of the draining sinus tract is often falsely positive and lacks specificity. Osteomyelitis management should always be guided by a bone biopsy.

Topic:

Infectious Diseases

Record # 55

Question/Fact:

A 58-year-old man presents to the emergency department with complaints of a cough and shortness of breath. He has a history of smoking two-packs per day for 40 years. Physical examination reveals a well-developed, well-nourished male appearing older than the stated age. He is afebrile. His chest is clear with distant breath sounds. The rest of the physical examination is benign.

Chest x-ray reveals a 2-cm mass in the right upper lobe. CT scan of the chest reveals a 2-cm spiculated mass with unilateral hilar lymph nodes. The patient undergoes fiberoptic bronchoscopy with biopsy of the endobronchial lesions and is noted to have adenocarcinoma.

What is the best therapy?

(A) Cisplatin and etoposide
(B) Radiation
(C) Surgical resection
(D) Palliation only

Answer:

(C) Surgical resection

Explanation:

This patient has stage IIa disease. This means he is still a candidate for surgery. The patient's lymph-node involvement is limited only to the ipsilateral hilar lymph nodes, which means he can still successfully undergo surgical resection. Without surgery, there is virtually no survival at five years. Surgical resection would even be possible with ipsilateral mediastinal disease. The presence of contralateral lymph nodes at any site makes surgical resection impossible.

Topic:

Hematology-Oncology

Record # 56

Question/Fact:

A 19-year-old male college student presents to the emergency department with acute mental status changes. He doesn't have any significant past medical history, except for a sore throat that started about a week ago. His parents suspect that he was using crack cocaine during his senior year in high school. They found him, confused and agitated, and called for an ambulance to pick him up from their home. The patient's father is suffering from allergic rhinitis, for which he is treated with diphenhydramine. The patient's mother uses digoxin, metoprolol, glyburide, haloperidol, and sertraline. They state that all medications are always locked in the drawer and are inaccessible.

The patient is confused, disoriented to time and place, and intermittently agitated. His temperature is 104.2 F, heart rate is 80/min, respiratory rate is 24/min, and blood pressure is 90/55 mm Hg. His skin is sweaty and pale, and his speech is slurred. There are persistent, involuntary movements of the facial musculature and extensor rigidity. The abdomen is normal. Laboratory studies show that his sodium and glucose levels are normal. The CPK is markedly elevated. The blood gas on room air shows: pH 7.29, pCO2 28 mm Hg, pO2 92 mm Hg, CO2 16 mm Hg, and O2 saturation 98%. The CT scan of the head is unremarkable. Intravenous fluids are started. What is the most effective management of this case?

(A) Activated charcoal and gastric lavage
(B) Diphenhydramine
(C) Bromocriptine
(D) Physostigmine

Answer:

(C) Bromocriptine


Explanation:

The neuroleptic malignant syndrome (NMS) is a catatonia-like state manifested by extrapyramidal signs, blood pressure changes, altered consciousness, and hyperpyrexia. Muscle rigidity, involuntary movements, confusion, dysarthria, pallor, and diaphoresis are present and may result in coma and death. Elevated creatine kinase, metabolic acidosis, and leukocytosis with a shift to the left are present early in about 50% of cases. Extrapyramidal signs are similar to Parkinson's disease, with spasmodic contractions of the face, extensor rigidity, carpopedal spasm, and motor restlessness. If blood pressure is low, administer fluids and pressor agents. For extrapyramidal signs, diphenhydramine is effective. Dopamine agonists, such as bromocriptine, are the most useful therapy. Dantrolene is used to alleviate muscle rigidity. Atropine, scopolamine, tricyclic antidepressants, and antihistamines will produce dryness of the mouth, dilated pupils, flushed skin, tachycardia, fever, myoclonus, and ileus. Antihistamines may cause convulsions, delirium, and tachycardia. For atropine intoxication resulting in hyperthermia and tachycardia, physostigmine should be given. Bradyarrhythmias and convulsions are a hazard with this medication, and it should not be used with tricyclic-antidepressant overdose. Gastric lavage has very little efficacy in removing pills from the stomach. It is only useful when you know that the ingestion occurred within an hour of arriving in the emergency department.

Topic:

Poisoning

Record # 57

Question/Fact:

A 37-year-old man presents to the clinic after noticing a painful ulcer at the base of his penis. On physical examination, he is afebrile with no rash or lymphadenopathy. There are three shallow ulcers at the base of his penis. There is no urethral discharge. A Darkfield examination of swab from the base of the ulcer is negative. The results of culture for herpes simplex virus (HSV) and Haemophilus ducreyi are positive. The results of HIV and VDRL tests are pending. The patient was started on acyclovir and azithromycin. Two days later, the patient presents with complaints of drooping of the right side of his face that is most noticeable when he tries to smile. The patient is unable to shut his right eye. What would you do next?

(A) CT scan of the head
(B) Intramuscular penicillin
(C) Increase the dose of acyclovir
(D) Start the patient on steroids
(E) Continue current therapy for longer

Answer:

(D) Start the patient on steroids

Explanation:

This patient presents with an ulcerative lesion of chancroid and herpes simplex virus (HSV). Darkfield examination was negative. This is the most sensitive test for primary syphilis. Penicillin is not necessary unless the VDRL or RPR is positive. Thus, waiting for the VDRL is recommended. Based on positive cultures for HSV and Hemophilus ducreyi, the patient was started on acyclovir and azithromycin. The patient then develops neurological findings consistent with a seventh cranial nerve or Bell's palsy, most likely caused by HSV. The head CT scan is not indicated and will not be helpful because the seventh cranial nerve palsy is essentially a peripheral neuropathy. Acyclovir has no effect specifically for the treatment of Bell's palsy. Steroids are the appropriate next step in treatment of this patient. Steroids have been shown to be effective in the treatment of the symptoms of Bell's palsy by reducing the inflammation of the seventh cranial nerve. They decrease inflammation of the nerve and lessen the pressure on the nerve as it travels through its bony canal in the face.

Topic:

Infectious Diseases

Record # 58

Question/Fact:

A 52-year-old woman from India is referred to your office by her dentist. She states that she was told as a teenager that she had a "heart murmur." On further questioning, she complains of having episodes of shortness of breath that worsens on exertion. Physical examination is significant for a widely split S2 and an additional diastolic sound followed by a mid-diastolic rumbling murmur. This is best heard at the fourth intercostal space at the left sternal border. The chest x-ray shows straightening of the left heart border. What is appropriate as the initial treatment of this patient?

(A) Balloon valvotomy
(B) Digoxin
(C) Surgical repair
(D) ACE inhibitors
(E) Diuretics

Answer:

(E) Diuretics

Explanation:

The patient has mitral stenosis as determined by the mid-diastolic extra sound, which is an opening snap followed by a murmur. The patient has mild symptoms, which were not even a complaint and were only elicited on review of systems. Mild mitral stenosis is best treated initially with diuretics. ACE inhibitors offer no benefit at all in mitral stenosis because they help with ventricular emptying, and patients with mitral stenosis have a problem with ventricular filling. Digoxin is useful for rate control in those patients who have atrial fibrillation. Otherwise, digoxin is useless in mitral stenosis. Balloon valvotomy is useful when diuretics don't control symptoms, generally when the valve area decreases to <1 square centimeter per meter of body surface area.

Topic:

Cardiology

Record # 59

Question/Fact:

A 22-year-old man presents to the emergency department with a 24-hour history of 8 to 10 episodes of liquid stools without blood. There is associated diffuse abdominal cramping pain relieved by each bowel movement. The patient denies tenesmus. There is no similar problem in the past, and no one else in the family has this problem. The patient also denies recent travel. His pulse rate is 94/min, and blood pressure is 148/96 mm Hg. There is no orthostatic hypotension, and his temperature is 37 C (98.6 F). His abdomen is soft and nontender. What is the best initial approach to this patient?

(A) Admit for observation
(B) Stool for cultures, ova, and parasites, and complete blood-count chemistry
(C) Empiric antibiotic therapy with trimethoprim/sulfamethoxazole or ciprofloxacin
(D) Reassurance and oral fluids
(E) Flexible sigmoidoscopy with mucosal biopsies

Answer:

(D) Reassurance and oral fluids

Explanation:

Most diarrheal illness is viral and self-limited. Diagnostic tests and medications are typically not needed. As long as the patient has no significant medical problems and can tolerate oral fluids, reassurance and discharge from the emergency room is appropriate.

Topic:

Gastroenterology

Record # 60

Question/Fact:

A 30-year old Asian woman has complaints of fatigue, body aches, and a fever for the last 2 weeks. Upon physical examination her temperature is 101.3 F, pulse is 76/min, respirations are 20/min, and blood pressure is 130/72 mm Hg. A systolic murmur is heard at the apical area radiating to the axilla. The first heart sound is diminished, and a third heart sound is heard. The chest x-ray shows no signs of cardiomegaly or congestive heart failure. The echocardiogram shows vegetations. Blood cultures are sent, and the patient is started on antibiotic therapy with vancomycin and gentamicin. One set of blood culture is positive for Streptococcus viridans.

After 8 days of hospitalization on the same antibiotics, the patient has the sudden onset of shortness of breath, orthopnea, and an episode of hemoptysis.

Physical examination currently shows a temperature of 99.6 F, pulse of 108/min, respirations of 28-30/min, and a blood pressure of 90/50 mm Hg. Bilateral crackles are heard. A holosystolic murmur is heard in the apical area. A repeat chest x-ray shows signs of pulmonary congestion. The echocardiogram shows flail leaflets with premature closure of the mitral valve. The left ventricular end systolic diameter is more than 50 mm, and the ejection fraction is 60%.

Which of the following is the most effective management for this patient?

(A) Send for repeat blood cultures and change antibiotics based on culture and sensitivity results
(B) Start the patient on digoxin and captopril immediately
(C) Continue antibiotics for 6 weeks and repeat a transthoracic echocardiogram
(D) Arrange for immediate mitral valve reconstruction
(E) Start coumadin

Answer:

(D) Arrange for immediate mitral valve reconstruction

Explanation:

This patient has acute severe mitral regurgitation (MR) from infective endocarditis. Moderate-to-severe congestive heart failure (CHF) due to valvular dysfunction is an indication for valvular surgery in patients with infective endocarditis. Mitral valve repair should be performed before irreversible left ventricular dysfunction occurs. The adequacy of mitral valve reconstruction can be assessed by transesophageal echocardiogram performed intraoperatively without interrupting the surgical procedure. Valve reconstruction has a lower mortality than does replacement and does not require lifelong anticoagulation. Better ventricular function with valvuloplasty may be due to a preservation of the chordae tendinae and papillary muscles. Following valve repair, anticoagulation is recommended permanently only if atrial fibrillation persists. Repeating blood cultures once they are positive adds little to the management. The best management in this patient is surgical repair and not medical therapy.

Digoxin is primarily useful only in mitral regurgitation for rate control if atrial fibrillation develops. In stable patients, ACE inhibitors can be useful to prevent further progression of regurgitant disease. This patient must undergo surgery as the best management, and besides that, the blood pressure is rather low already.

Topic:

Cardiology

Record # 61

Question/Fact:

A 55-year-old man is brought to your office by his wife for complaints of general slowing of movements, frequent falls, and difficulty in turning over in bed or getting up from a sitting position. His wife also reports that he has difficulty sleeping, appears more depressed, fearful, and anxious, and refuses to join social gatherings. He has episodic symptoms of delirium. He works as an accountant and has been unable to work lately. He is more forgetful and is misplacing things. These symptoms have been present for a year. The patient has visual hallucinations. Physical examination shows a normal blood pressure and no signs of cardiac or vascular disease. Neurological examination reveals a slight impairment in cognition. He is unable to perform serial sevens. His speech is soft and slow, and there is normal upward and downward gaze, with micrographia, tremors, and hypometria. The plantar responses are extensor, and there is a festinating gait. His memory is impaired. What is the most likely diagnosis?

(A) Parkinson's disease
(B) Diffuse Lewy body disease
(C) Progressive supranuclear palsy
(D) Shy-Drager syndrome (multiple system atrophy)
(E) Corticobasal ganglionic degeneration

Answer:

(B) Diffuse Lewy body disease

Explanation:

This patient has all the symptoms and signs of Parkinson's disease (PD). In addition, he has the early onset of dementia, visual hallucinations, and cognitive fluctuations, which are pathognomonic of diffuse Lewy body disease. These patients have clinical parkinsonism combined with dementia, as well as symptoms similar to delirium occurring in an episodic fashion. Dementia rarely occurs on initial presentation of PD and is usually a very late finding. PD patients do not have hallucinations but may develop them as a side effect of dopaminergic treatment.

Patients with progressive supranuclear palsy have impairment in downward gaze initially and later in upward and lateral conjugate gaze. These patients complain of difficulty seeing. Mild to moderate dementia is a late sign, and tremors almost never occur. Multisystem atrophy or Shy-Drager syndrome leads to orthostatic hypotension, lightheadedness, incontinence, sexual impotence, and other autonomic symptoms besides parkinsonism. Corticobasal ganglionic degeneration is another form of multisystem degeneration. These patients have apraxia, jerky tremor, alien limb phenomenon, and nonfluent aphasia.

Topic:

Neurology

Record # 62

Question/Fact:

A 40-year-old Asian man with a past medical history of diabetes, diagnosed two years ago, and HIV presents to your office complaining of "bloody" urine for 2 days. The patient claims that he has been suffering from a "nasty cold" for the past 2 days. He claims that he has been feeling more fatigued than usual. His medications include zidovudine, didanosine, indinavir, metformin, and lisinopril. He denies tobacco, alcohol, or illicit drug use. On physical examination, vital signs are: temperature 97.9 F; pulse 98/min, and blood pressure 130/80 mm Hg. The heart, lung, and abdominal examinations are normal. There is no edema. Laboratory studies reveal:

White blood cells 6,700/mm3; hematocrit 41%; platelets 410,000/mm3; potassium 4.6 mEq/L; BUN 20 mg/dL; creatinine 1.4 mg/dL; glucose 155 mg/dL; albumin 4.5 g/dL. CD4 count 490; viral load <50 copies. Urinalysis reveals dysmorphic red cells, no white cells or bacteria. There is trace protein and a few red cell casts. Twenty-four hour urine protein 250 mg; C3 normal; C4 normal; ASO negative; serum IgA normal. Electron microscopy reveals mesangial deposits.

What is the most accurate diagnosis of this patient?

(A) Poststreptococcal glomerulonephritis
(B) IgA nephropathy
(C) HIV nephropathy
(D) Diabetic nephropathy
(E) Minimal change disease
(F) Indinavir-induced renal insufficiency

Answer:

(B) IgA nephropathy

Explanation:

Immunoglobulin A (IgA) nephropathy (Berger's Disease) is the most common form of acute glomerulonephritis in the United States. IgA nephropathy is marked by IgA deposition in the mesangium of the glomerulus. The etiology is unknown. Patients often present with gross hematuria, as seen in this patient whose hematuria developed 2 days after a "bad cold" (upper respiratory infection), which goes along with the diagnosis of IgA nephropathy. A patient who develops poststreptococcal glomerulonephritis will develop hematuria anywhere between 1 to 3 weeks, with an average onset of 7 to 10 days. Poststreptococcal glomerulonephritis would give hypertension, edema, an elevation of the ASO titer, and low complement levels. The presentation of hematuria, hypertension, proteinuria, and decreased glomerular filtration rate (impaired renal function) goes along with nephritis. Nephrotic syndrome would be considered if there were evidence of hypoalbuminemia, hyperlipidemia, edema, and heavy proteinuria (>3.5 g/24 h). Fifty percent of patients with IgA nephropathy can have a normal serum IgA level. Therefore, further testing such as a renal biopsy would be indicated. This patient underwent a biopsy, which revealed mesangial deposits. On immunofluorescence, one would see IgA deposits, which will help in making the definitive diagnosis.

HIV nephropathy, diabetic nephropathy, and minimal change disease all usually present with a picture of nephrotic syndrome. In HIV nephropathy, light microscopy reveals focal and segmental glomerulosclerosis, and electron microscopy reveals fusion of the foot processes. It is almost impossible to have HIV-associated nephropathy with a CD4 count >200 and an undetectable viral load. Indinavir-associated renal failure is a tubular defect and would not give red cell casts or glomerular deposits on the biopsy.

Minimal change disease is most commonly seen in children, although it can be seen in adults. A patient with minimal change disease will present with massive proteinuria and edema, which are absent in this patient. Light microscopy and immunofluorescence testing of the biopsy will be negative. Electron microscopy would reveal fusion of the epithelial foot processes. This patient is unlikely to have diabetic nephropathy because it usually takes much longer than the two years that this patient has had diabetes. A patient often develops microalbuminuria within 10 to 15 years after diagnosis of diabetes. Overt proteinuria usually develops 3 to 7 years thereafter.

Topic:

Nephrology

Record # 63

Question/Fact:

A 75-year-old man is admitted to the hospital with complaints of shortness of breath, chest pain, and palpitations for the last day. He has a past medical history of diabetes mellitus and hypertension. Three years ago, he underwent coronary artery bypass grafting. His medications at home include metoprolol, nitroglycerin, aspirin, digoxin, and metformin. Sometime in the past he was prescribed coumadin, but then it was stopped for an unknown reason.

On admission, his blood pressure is 90/40 mm Hg, heart rate is 120/minute, and respiratory rate is 24/min. The patient appears pale and slightly diaphoretic. The jugular venous pressure is elevated. The heart rhythm is irregularly irregular. On lung auscultation, there are bibasilar crackles and an S4 gallop. Two sets of cardiac enzymes are negative. The EKG shows atrial fibrillation with a ventricular response of 124/min and T-wave inversion in leads V1 to V4. These T-wave inversions were also was present on an EKG six months ago. The chest x-ray shows pulmonary edema and cardiomegaly. Transthoracic echocardiography reveals moderate left ventricular hypertrophy and an ejection fraction of 45%. The first troponin is negative. What is your next step in management of this patient?

(A) Digoxin, for a total of 1 mg over 24 hours
(B) Direct current cardioversion
(C) Procainamide
(D) Heparin
(E) Transesophageal echocardiogram

Answer:

(B) Direct current cardioversion

Explanation:

This patient presents with pulmonary edema and signs of hemodynamic compromise (hypotension, dyspnea, congestion on lung exam, pulmonary edema on chest x-ray, and chest pain) related to uncontrolled atrial fibrillation. The therapy of choice for any unstable patient is rapid direct current cardioversion. It is successful 80% of the time if major structural heart disease is not present in the atrium. Pharmacological cardioversion is successful 40 to 50% of the time at most. Still, chemical cardioversion is considered a first-line of therapy by many physicians in a hemodynamically stable patient. Drug therapy with sotalol, procainamide, or amiodarone is useful for maintenance of sinus rhythm after cardioversion. It is reasonable to attempt chemical cardioversion on any patient who fails electrical cardioversion.

If the patient has been in atrial fibrillation for over 48 hours and is at risk of having formed a thrombus in the atria, he should be anticoagulated. If the patient is hemodynamically stable, this can be accomplished with coumadin for three weeks prior to the cardioversion. More urgent cardioversion can be performed after transesophageal echocardiogram to rule out the presence of a clot in the left atrium. After this, cardioversion is carried out in the setting of systemic anticoagulation. Heparin can be used to rapidly anticoagulate the patient, followed by coumadin for three weeks.

Topic:

Cardiology

Record # 64

Question/Fact:

A 62-year-old previously healthy woman presents to your office with complaints of low-grade fever, fatigue, malaise, and progressive numbness of her feet over the last three months. The patient also complains of frequent episodes of diffuse abdominal pain, which is associated with nausea and vomiting and begins approximately thirty minutes after meals. The patient states that she lost 25 pounds in spite of a normal appetite over the last several months. Six weeks ago, she developed mild inflammatory polyarthritis of the hands. She used ibuprofen with no significant relief. She has physical signs suggesting a mononeuritis in the left median nerve distribution. Today her blood pressure is 160/100 mm Hg, and her heart rate is 72/min. Her blood pressure was previously 130/80 mm Hg. Which of the following tests would you use to establish the correct diagnosis?

(A) Abdominal CT scan
(B) Serum rheumatoid factor
(C) Erythrocyte sedimentation rate
(D) Sural nerve biopsy
(E) Skin biopsy

Answer:

(D) Sural nerve biopsy

Explanation:

This patient presents with constitutional complaints and has clinical evidence of impaired functioning of multiple organs. These findings make vasculitis a distinct diagnostic possibility, and they are typical of polyarteritis nodosa (PAN). Classic PAN involves only medium-sized vessels. Clinical findings depend on arteries involved. Common symptoms of PAN include fever, constitutional symptoms, abdominal pain, livedo reticularis, mononeuritis multiplex, anemia, and an elevated erythrocyte sedimentation rate. Pain in the extremities is often a prominent early feature and is associated with arthralgias, myalgias, or neuropathy. The combination of mononeuritis multiplex and features of systemic illness is one of the earliest signs of PAN. Foot drop is the most frequent manifestation.

Rheumatoid arthritis is a systemic illness that can be complicated by small to medium-sized vessel vasculitis. The only finding supporting this diagnosis in this case is mild joint complaints. Biopsy of involved tissue or an angiogram is the most direct way to make a diagnosis in PAN. Angiogram is not one of the choices in this case; therefore, sural nerve biopsy is the answer. The foot numbness suggests that the sural nerve is involved. Biopsy of symptomatic sites, such as nerves, muscles, lungs, or kidneys, has a high sensitivity and specificity. An alternative method is a three-vessel abdominal angiography, which is positive in 80% of the patients. The erythrocyte sedimentation rate is almost always elevated in PAN but is not specific.

Topic:

Rheumatology

Record # 65

Question/Fact:

A 78-year-old man comes to your office complaining that his arm shakes. This had started a year ago and has gotten progressively worse. He noticed that it gets worse when he is nervous, watching TV, or just sitting. It gets better when he is working with his hands. The patient is concerned because his father had a similar disease, which eventually made him senile. He asks you for a cure. He has a mild resting tremor of both hands on examination and a tiny amount of muscular rigidity. He is not orthostatic, and his gait and facial movement are normal. What will you do for this patient?

(A) Levodopa/carbidopa
(B) Amantadine
(C) Benztropine
(D) Selegiline
(E) Beta-blockers

Answer:

(B) Amantadine

Explanation:

The presentation of Parkinson's disease (PD) consists of tremor, rigidity, and bradykinesia. To relieve mild symptoms of the disease, such as in this patient who has a tremor alone, patients can use Amantadine or anticholinergic agents, such as benztropine. Anticholinergic agents should not be used in older patients because they are less able to tolerate the adverse effects such as dry mouth, constipation, blurry vision, confusion, and hallucinations. Anticholinergics are a good choice in younger patients under the age of 60 with a tremor. Amantadine is the answer in this case because he is 78 years old and presents predominantly with a tremor. The tremor typical of essential tremor occurs with action, whereas the tremor of PD occurs at rest, such as in this case.

Patients with more severe disease, but not so severe that it interferes with activities of daily living, can use dopamine agonists, such as pramipexole and ropinirole. They may also have neuroprotective effects as well. Levodopa/carbidopa is used in the most severe forms of the disease and has the most bothersome side effects, such as dyskinesias and behavior abnormalities. Selegiline decreases oxidative damage and may decrease progression of the disease. Selegiline is best used as adjunctive therapy in those receiving levodopa. When the question asks what drug will delay the progression of disease, answer selegiline or the dopamine agonists. Beta-blockers are a wrong choice because they are used to control an "essential" tremor, but not the tremor of PD.

Topic:

Neurology

Record # 66

Question/Fact:

An 80-year-old, Russian-speaking lady is admitted to the hospital with shortness of breath and weakness. On the floor, the patient is treated for an exacerbation of congestive heart failure. While in hospital, the patient develops right lower extremity weakness. On physical examination, she is found to be a confused, obese, elderly woman with a pulse of 80/min and a blood pressure of 160/100 mm Hg. On neurological examination, she is found to be indifferent to her surroundings and confused, with a mild short-term memory deficit. Cranial nerve function is normal. There is decreased vibration and proprioceptive sense in the toes bilaterally. Motor weakness is found in the right lower limb and proximal right upper limb. The leg weakness is much more severe than the arm weakness. Planter reflexes show up-going toes. A CT scan of the head shows no hemorrhage or mass effect. Which of the following is most likely to be found in this patient?

(A) Defects in the fluency of her speech
(B) Urinary incontinence
(C) Problems with repetition
(D) Agraphia
(E) Nominal aphasia

Answer:

(B) Urinary incontinence

Explanation:

From the history and physical examination, it is clear that the muscular weakness is from a stroke in the distribution of the anterior cerebral artery. Occlusion of the anterior cerebral artery causes weakness of the contralateral lower limb and proximal part of the upper limb. Compromised perfusion of the cerebral cortex on the left side may affect all components of language function. However, in the case of occlusion of the anterior cerebral artery, some components of language function, like writing, naming, repetition, and fluency, are not affected. This is because the cerebral structures responsible for these functions are located more posteriorly. Urinary incontinence is common, particularly when behavioral disturbances are present.

Topic:

Neurology

Record # 67

Question/Fact:

A 60-year-old man is brought to the emergency department after being found unresponsive by his wife. The patient has a history of atrial fibrillation, congestive heart failure, coronary heart disease, and depression. His medications are aspirin, amitriptyline, digoxin, and enalapril. He is unresponsive to verbal or tactile stimuli. His pulse is 70/min, respirations are 8/min, and blood pressure is 96/50 mm Hg. His pupils are normal. His lungs have bibasilar crackles, and his heart is normal. An EKG shows a regular sinus rhythm with no Q waves or ST-T changes. Laboratory studies reveal: sodium 136 mEq/L, potassium 4.0 mEq/L, chloride 92 mEq/L, bicarbonate 12 mEq/L, BUN 18 mg/dL, creatinine 2.2 mg/dL, glucose 90 mg/dL, and calcium 8.0 mg/dL. An arterial blood gas shows a pH of 7.28, a pCO2 of 35 mm Hg, and a pO2 of 60 mm Hg on room air. His urinalysis shows 1+ protein and crystalluria. What would be the first test performed to establish the diagnosis?

(A) Tricyclic levels
(B) Digoxin level
(C) Glycolic acid level
(D) Acetaminophen level

Answer:

(C) Glycolic acid level

Explanation:

This patient is suffering from ethylene glycol toxicity. He has a history of coronary heart disease, but the EKG is not suspicious for an acute coronary syndrome, which would have ST changes. Digoxin toxicity would not result in such severe mental-status changes and would probably give abnormalities on the EKG. This patient has a metabolic acidosis with an increased anion gap. Glycolic acid levels will confirm a diagnosis of ethylene glycol poisoning. Ethylene glycol will give a high anion-gap metabolic acidosis. Ethylene glycol and its metabolites cause central nervous system depression. The glycolic acid metabolite is even more toxic than is ethylene glycol. It also causes tubular damage to the kidney. Oxalic acid may precipitate as calcium oxalate crystals in the heart, brain, pancreas, lung, kidneys, and urine and cause hypocalcemia and crystaluria. As little as one swallow of pure ethylene glycol can result in a potentially toxic blood concentration. Effects include nausea, vomiting, sweating, slurred speech, ataxia, nystagmus, and lethargy 30 minutes after ingestion. Hypocalcemia occurs in one-third of patients. Leukocytosis is present in most. In severe cases, respiratory distress syndrome, cyanosis, and pulmonary edema may be seen. Acute tubular necrosis manifested by proteinuria, oliguria, and anuria typically becomes evident 12 to 24 hours following ingestion.

Topic:

Poisoning

Record # 68

Question/Fact:

A 24-year-old man with a known history of asthma since childhood is brought to the emergency room by his girlfriend for increasing shortness of breath and wheezing over the past few days. The patient had tried to overcome his respiratory difficulty with extra puffs of his albuterol inhaler, but no significant improvement was noted. The patient has been to the emergency department in the past for similar complaints but was never intubated. He is started on 35% oxygen, albuterol via nebulizer, and corticosteroids intravenously. He is in respiratory distress with the use of his accessory respiratory muscles. He is tachypneic, and the oxygen saturation is 93%. Chest auscultation reveals bilateral wheezing with good air entry. An arterial blood gas shows a pH of 7.48, pCO2 of 30 mm Hg, and a pO2 of 102 mm Hg. The chest x-ray is normal. He is closely monitored over the next hour while receiving continuous nebulizer treatments. On follow-up examination, the patient is lethargic but does not appear to be in respiratory distress. There is minimal accessory respiratory muscle use and silent lung fields. A repeat blood gas shows a pH of 7.25, a pCO2 of 65 mm Hg, and a pO2 of 72 mm Hg. What is the next best step in treating this patient?

(A) Terbutaline
(B) Epinephrine
(C) Increase his percent oxygen to improve his saturation level
(D) Intubation
(E) Pulmonary function testing
(F) Theophylline
(G) Zafirlukast

Answer:

(D) Intubation

Explanation:

This patient has developed acute respiratory acidosis and must be intubated. He has a rising pCO2 and a dropping pH. The patient is having impending respiratory failure. Terbutaline is a beta-agonist with very limited efficacy. Theophyline and aminophylline have some mild benefit but will not be sufficiently strong to immediately reverse his respiratory failure and CO2 accumulation. Zafirlukast is a leukotriene inhibitor and will not work acutely to reverse his problem. No matter how much you increase his level of oxygen delivery, it will not solve what is primarily a ventilatory problem. Epinephrine is not more effective than the inhaled beta-agonists he is already receiving. He will be dead before you can get the results of pulmonary function testing.

Topic:

Pulmonary

Record # 69

Question/Fact:

A 24-year-old man was admitted to the emergency department a week ago because of a fever for ten days prior to admission. He was not dyspneic on admission. He has a history of injection drug use. He was started on vancomycin and gentamicin on admission before blood cultures were obtained. On physical examination, you find a diaphoretic man in mild respiratory distress. He has scattered bruises all over his body. Lung examination reveals bibasilar crackles. Heart examination reveals a low-pitched, early diastolic murmur at the left sternal border. The patient has 1+ pitting edema of the bilateral lower extremities. Currently, he has a temperature of 101.5 F. What is most important next step for this patient?

(A) Stop the antibiotics and get blood cultures
(B) CT scan of chest, abdomen, and pelvis
(C) Transthoracic echocardiogram
(D) Continue vancomycin and gentamicin and reassess in 1 to 2 more days
(E) Surgery consult

Answer:

(E) Surgery consult

Explanation:

This patient seems to have developed acute aortic regurgitation secondary to endocarditis. He needs valve replacement because he is symptomatic and deteriorating despite the use of antibiotics. However, you can't stop the antibiotics because of the progressive nature of his disease. Removing the source of the infection with valve replacement as soon as possible will stop the infection, as well as improve his hemodynamic status. This is also the best way to improve his respiratory status. If he is still febrile after a week of vancomycin and gentamicin, it is unlikely that a few more days will make any difference. Although an echocardiogram should be performed, he will still need evaluation for replacement of the valve. He has a clear murmur of aortic regurgitation and worsening shortness of breath. If you were going to do an echocardiogram, a transesophageal study would be preferred anyway.

Topic:

Cardiology

Record # 70

Question/Fact:

A 57-year-old woman presents to the emergency department with the sudden onset of severe midabdominal pain of one hour in duration with nausea and vomiting. She describes this pain as the worst pain she's ever had. She states that over the last three months, she has had a low-grade fever, fatigue, malaise, and progressive numbness of her feet. Over the last several months, she has developed frequent episodes of diffuse abdominal pain, associated with occasional nausea and vomiting, approximately thirty minutes after meals. She has lost 25 pounds over the last two months. There has been no change in her bowel habits. She has a history of chronic hepatitis B, diagnosed four years ago. She has no history of atherosclerotic heart disease or atrial fibrillation. Six weeks ago, the patient developed mild inflammatory polyarthritis of her hands. She also has physical signs suggesting a mononeuritis in the left median nerve distribution. On physical examination, her abdomen is relatively soft and nontender without any signs of peritonitis. The stool is guaiac positive. Which of the following tests is the most useful in establishing the correct diagnosis?

(A) Abdominal CT scan
(B) Enteroscopy
(C) Colonoscopy
(D) Abdominal angiogram
(E) Plain abdominal film
(F) Skin biopsy
(G) P-ANCA

Answer:

(D) Abdominal angiogram

Explanation:

This patient presents with signs of mesenteric vasculitis. Classic polyarteritis nodosa (PAN) involves only medium-sized vessels. Clinical findings depend on which arteries are involved. Symptoms of PAN include fever, constitutional symptoms, abdominal pain, mononeuritis multiplex, anemia, and an elevated ESR. The combination of mononeuritis multiplex and features of a systemic illness is one of the earliest specific clues to the presence of PAN. The most common lesion in the mononeuritis is foot-drop. Diffuse abdominal pain beginning about 30 minutes after meals is common in PAN. This is also known as abdominal angina. Infarction compromises the function of major viscera and may lead to cholecystitis or appendicitis. Other patients with abdominal angina present with what simulates a perforated abdominal organ. This can be caused by emboli secondary to atrial fibrillation, diffuse atherosclerotic disease, or low flow to the superior mesenteric artery from hypotension. This patient does not have any cardiac disease, and her symptoms are most likely caused by vasculitis. Classically, the patient's pain is far out of proportion to examination findings. An angiogram is needed to confirm mesenteric ischemia as a result of PAN.

An abdominal CT scan is too insensitive to detect vasculitis of the mesenteric vessels. Enteroscopy is done when there is the suspicion of small bowel bleeding, and other forms of endoscopy have been unrevealing. A skin biopsy might be useful if there were skin lesions. P-ANCA testing in general is too inaccurate to be very useful in any disease. Plain abdominal films are only good for excluding obstruction.

Topic:

Rheumatology

Record # 71

Question/Fact:

A 79-year-old woman presents to emergency department complaining of the acute onset of shortness of breath after arriving home from the airport. She has pleuritic chest pain and a dry cough but denies fever. She has no other medical history and uses no medications. She claims that she had no previous episodes of this nature. On physical examination, she has a temperature of 99.5 F, a heart rate of 110/min, a respiratory rate of 28/min, and a blood pressure of 110/60 mm Hg. The lungs are clear. A blood gas on room air shows a pH of 7.49, a pCO2 of 28 mm Hg, and a pO2 of 80 mm Hg. The chest x-ray is normal, and the EKG shows only sinus tachycardia. The D-dimer by ELISA is elevated at 750 ng/ml, and the V/Q scan is read as a low probability study. The Doppler examination of lower extremities is negative for thrombi. What is the most accurate test for this patient?

(A) CT scan of the chest
(B) Contrast venography of the lower extremities
(C) CT angiography of the chest
(D) Echocardiography
(E) Latex Agglutination D-dimer

Answer:

(C) CT angiography of the chest

Explanation:

In a patient with a high index of suspicion for a pulmonary embolism with an unrevealing initial evaluation, additional testing should be pursued. High suspicion is more important than a normal chest x-ray, a low-probability V/Q scan, or a Doppler negative for clots. Although a spiral CT scan may be helpful in diagnosing a pulmonary embolism, this patient presented with pleuritic chest pain, cough, and dyspnea, with no other signs of right-heart failure. This is more indicative of a small emboli located distally near the pleura.

A spiral CT scan is most accurate for large, proximal clots, not small distal clots. Overall, the spiral CT scan only has a sensitivity of 70%. Contrast venography of the legs has mostly been replaced by ultrasonography (Doppler) because venography is costly, uncomfortable, and on occasion, induces an allergy to contrast. In addition, the Doppler of the legs is so sensitive that venography adds little to the accuracy. Besides that, 30% of pulmonary emboli do not originate in the legs, and a normal study does not exclude a pulmonary embolus. Echocardiography may be used in differentiating between illness requiring different treatments, such as an acute myocardial infarction, pericardial tamponade, aortic dissection, and right-sided heart failure secondary to a pulmonary embolus. The echocardiogram, however, is not as accurate as the CT angiogram. The CT angiogram is more accurate than the spiral CT scan of the chest and is less invasive than a pulmonary angiogram. The latex agglutination D-dimer is a qualitative test and is less sensitive than the ELISA D-dimer test, which was already done for this patient.

Topic:

Pulmonary

Record # 72

Question/Fact:

A 45-year-old woman comes to the office complaining of lower abdominal pain and urinary urgency and frequency for the past three days. She has had three episodes of cystitis over the last six months. Ultrasonography, cystoscopy, and bladder voiding studies were normal. Her past medical history is otherwise noncontributory. She is sexually active and has a boyfriend. She has been using vitamin C to acidify her urine, as well as voiding urine immediately after sex. Her temperature is 100.4 F. She has mild tenderness on palpation of the suprapubic area. Laboratory tests show a white cell count of 8,500/mm3, with a glucose of 89 mg/dL, a BUN of 25 mg/dL, and a creatinine of 0.8 mg/dL. Her urinalysis shows more than 50 red cells and more than 50 leukocytes per high-power field. The urine Gram stain shows gram-negative rods. What would you recommend to this patient?

(A) Ceftriaxone and doxycycline
(B) Trimethoprim/sulfamethoxazole orally for 3 days
(C) Trimethoprim/sulfamethoxazole orally for 3 days and then one at night for 6 months
(D) Intravenous antibiotics
(E) Repeat cystoscopy

Answer:

(C) Trimethoprim/sulfamethoxazole orally for 3 days and then one at night for 6 months

Explanation:

This patient presents with recurrent acute cystitis, which is characterized by the presence of dysuria, suprapubic pain, hematuria, bacteremia, and pyuria. Uncomplicated urinary tract infections (UTI) are common in otherwise healthy young women. Acute, uncomplicated episodes of symptomatic infection can be managed with a 3-day course of oral therapy. Three-day treatment is preferred because it is more effective than single-dose therapy and equally as effective as a 7- to 10-day course of treatment. Frequently, recurrent infections occurring more than three times per year can be managed by long-term prophylaxis with trimethoprim/sulfamethoxazole (TMP-SMZ), nitrofurantoin, or a fluoroquinolone as a single bedtime dose or following intercourse. Prophylaxis is highly effective for preventing recurrent infections. The risk of recurrence is still high once prophylaxis is stopped, and it may need to be resumed. Before the patient is started on prophylactic treatment, it is necessary to rule out anatomical defects, stones, fistulas, etc., so a thorough urological evaluation is needed. This patient has already undergone ultrasonography and cystoscopy; it is therefore not necessary to repeat the cystoscopy at this time. Intravenous antibiotics are recommended for the patients who are extremely ill or are unable to take oral medications. Ceftriaxone and doxycycline are recommended as a single dose in those with a simple urethritis. She has no urethral discharge but does have clear suprapubic tenderness.

Topic:

Infectious Diseases

Record # 73

Question/Fact:

A 26-year-old woman presents to the local emergency room with the sudden onset of shortness of breath. She occasionally smokes cigarettes. She has a respiratory rate of 28/min and a pulse of 110/min and a normal temperature. Initial laboratory tests show: WBC 9,000/mm3; hematocrit 39%; platelets 330,000/mm3; prothrombin time (PT) 12 seconds; partial thromboplastin time (PTT) 85 seconds.

The chest x-ray is normal, and the ventilation-perfusion (V/Q) scan reveals a high probability for pulmonary embolus. She is started on full-dose intravenous heparin. When anticoagulation is stopped, and a full evaluation can occur, which of the following is the most specific test to confirm her diagnosis?

(A) Antithrombin III level
(B) Mixing study
(C) VDRL and FTA
(D) Factor VIII inhibitor assay
(E) Russell's viper venom time

Answer:

(E) Russell's viper venom time

Explanation:

This patient most likely has a lupus anticoagulant. She is young and has none of the known risks for a hypercoagulable state (thrombophilia), such as malignancy, immobility, recent surgery, pregnancy, or lower extremity trauma. This is precisely the type of patient that should undergo evaluation for thrombophilia. The clue to the diagnosis is an elevated PTT at baseline. The Russell's viper venom time is the most specific assay for the lupus anticoagulant (LA).

A mixing study would be abnormal in this patient, but this would only mean there was an antibody inhibitor present. The mixing study cannot distinguish between the LA, factor inhibitors, or other antiphospholipid antibodies, such as anticardiolipin antibodies. Although the LA is associated with a false-positive VDRL, this would also be nonspecific. Antithrombin III deficiency presents with a normal PTT, which would be difficult to raise with heparin therapy. Factor VIII inhibitors present with bleeding, not thrombosis.

Topic:

Hematology-Oncology

Record # 74

Question/Fact:

A 66-year-old man with hypertension and diabetes presents to the emergency department two hours after developing acute weakness of the left side of his body. He fell from a chair at home while watching TV. He lost consciousness and was noted by his wife to have left arm and leg twitching, which resolved spontaneously at home. His current medications are aspirin, metoprolol, and metformin, with which he is compliant. On examination, he is alert and awake with a blood pressure of 190/100 mm Hg. He has dysarthric speech and left-sided face, arm, and leg weakness. There is no evidence of seizure activity in the emergency department. A head CT scan is done in the emergency department (about 2.5 hours after the onset of symptoms) that showed bilateral cortical atrophy and a lacunar infarction of the left putamen. There is no hemorrhage. What is the most appropriate therapeutic option at this stage?

(A) Control blood pressure, then give tPA
(B) Control blood pressure and add clopidogrel
(C) Start intravenous heparin
(D) Load with phenytoin and add clopidogrel
(E) Give tPA immediately

Answer:

(D) Load with phenytoin and add clopidogrel

Explanation:

This patient has two contraindications to thrombolytic therapy with tPA, which are severe hypertension and seizures at the onset of the stroke. While the hypertension may be controlled, the fact that this patient had a seizure should make one think of a possibility of a Todd's paralysis, in which case the patient should not be given tPA. Todd's paralysis is a transient, focal, neurological deficit occurring just from a seizure and resolving spontaneously. We need to control the seizures in this patient with phenytoin. Clopidogrel is added because of the possibility of having a stroke while on aspirin.

Heparin is rarely used for a stroke. Most patients do not receive heparin unless there is atrial fibrillation, a stroke in evolution with progressively worsening neurological deficits, or basilar artery thrombosis. It is not routinely used for patients in sinus rhythm with large neurological deficits because it can lead to an increased risk of intracranial hemorrhage. Thrombolytic therapy is indicated for an acute ischemic stroke when a patient presents within three hours of the onset of the neurological deficit. You must first obtain a baseline CT scan of the head to exclude an intracranial hemorrhage. Contraindications to the use of thrombolytics include:

• When the time of onset cannot be determined, such as a stroke recognized upon wakening
• Previous stroke or head injury within the past three months
• A prior history of intracranial bleed
• Active internal bleeding or gastrointestinal bleeding within the preceding 21 days
• Recent intracranial surgery or major surgery within past 14 days
• Intracranial neoplasm, arteriovenous malformations, or aneurysms
• Uncontrolled hypertension with a systolic blood pressure above 185 mm Hg or a diastolic pressure above 110 mm Hg
• An isolated, mild, neurological deficit that is rapidly improving
• A blood glucose level of <50 or >400 mg/dL, or seizures at the onset of stroke
• A known bleeding diathesis, such as current warfarin use with a prothrombin time >15 seconds or a platelet count <100,000/mm3. Aspirin taken previously does not exclude patients from the use of thrombolysis.
• • • •
Topic:

Neurology

Record # 75

Question/Fact:

An 18-year-old woman presents to the emergency department with a headache and dizziness for approximately three days. She states that the pain has been continuous and dull. She denies head trauma, visual changes, nausea, vomiting, photophobia, or fever. She states that she has "depression" and is reluctant to discuss any further history. She did not want to come but her "mother made her." Her medications are "an antidepressant." Physical examination shows a heart rate of 106/minute, and a blood pressure of 106/68 mm Hg. Her heart, lung, and abdominal examinations are normal. She has minor scrapes on the knuckles of her left hand. Labs show:

Sodium 126 mEq/L, potassium 3.6 mEq/L, chloride 96 mEq/L, BUN 28 mg/dL, creatinine 1.1 mg/dL, glucose 90 mg/dL. Serum bicarbonate 32 mEq/L, magnesium 1.6 mg/dL. Urine and serum toxicology screens are negative. Urinalysis shows a specific gravity of 1.010, protein 1+, and ketone trace with no white or red cells. Urine sodium is 88 mEq/L, and the urine osmolality is 130 mOsm/kg H2O.

Which of the following is the most likely diagnosis and treatment?

(A) SIADH secondary to SSRI; fluid restriction
(B) Pseudohyponatremia; fluid restriction, treat with insulin
(C) Simple dehydration; hydrate with 3% saline and correct magnesium
(D) Diuretic abuse; hold diuretic and hydrate with normal saline
(E) Depression-associated SIADH; start normal saline with magnesium supplement

Answer:

(D) Diuretic abuse; hold diuretic and hydrate with normal saline

Explanation:

This appears to be a hypovolemic hyponatremia. Diuretic abuse is seen in depressed young women. The BUN/creatinine and vital signs support a state of dehydration. However, the BUN must be viewed with caution because it is so dependent upon diet. The urine sodium suggests a mechanism of salt wasting or diuretic use. The treatment for this type of hyponatremia is hydration with normal saline. Although SIADH is seen with SSRI use, it is usually a euvolemic hyponatremia. This patient is hypovolemic based on the BUN/creatinine ratio, tachycardia, and borderline low blood pressure. In addition, a high serum bicarbonate suggests a volume-contraction metabolic alkalosis, as well as alkalosis from chloride wasting from a diuretic. The calculated serum osmolarity of 267 mg/dL is greater than the urine osmolality, suggesting that appropriate dilution of the urine is occurring in a patient with hyponatremia. SIADH gives an increased urine sodium with an inappropriately high urine osmolality.

Simple dehydration would result in a volume-contracted state and hypernatremia. Treatment with 3% saline is not necessary in a patient with hyponatremia producing symptoms as mild as this.

Topic:

Nephrology

Record # 76

Question/Fact:

A 46-year-old man comes to the clinic with a fever, cough, and 20-lb weight loss over the past two and a half months. The chest x-ray shows a right middle lobe infiltrate with ipsilateral hilar lymphadenopathy. The sputum acid-fast stain is positive. Mycobacterium tuberculosis is identified by polymerase chain reaction (PCR). His medications are lamivudine, zidovudine, and ritonavir. His CD4 count is 225/μL with an undetectable viral load. The rate of isoniazid resistance is documented to be 6% in his community. Which regimen is the best while waiting for drug susceptibility?

(A) Isoniazid, rifampin, and pyrazinamide for 2 months, followed by isoniazid and rifampin for 4 months
(B) Isoniazid, rifampin, and streptomycin for 6 months, and substitute nevirapine for lamivudine
(C) Isoniazid, rifabutin, pyrazinamide, and ethambutol for 6 months, and substitute efavirenz for ritonavir
(D) Isoniazid, rifabutin, and pyrazinamide for 2 months, followed by INH and rifabutin for 4 months
(E) Stop all HIV medications until the treatment for tuberculosis is complete

Answer:

(C) Isoniazid, rifabutin, pyrazinamide, and ethambutol for 6 months, and substitute efavirenz for ritonavir

Explanation:

The most commonly used regimen for tuberculosis consists of isoniazid, rifampin, pyrazinamide, and ethambutol administered daily for 2 months, followed by isoniazid and rifampin for 4 months. Unless the rate of resistance to isoniazid is documented to be less than 4% in the community, ethambutol or streptomycin is used until the organism is known to be fully susceptible to all drugs used.

The management of tuberculosis is not necessarily different in HIV-infected patients in terms of the initial choice of medications or the duration of therapy. There is no proof that extending the length of therapy from 6 to 9 months is necessary. HIV-infected persons who adhere to standard regimens of treatment for tuberculosis do not have an increased risk of treatment failure or relapse. This is particularly true in a patient such as this who has >200 CD4 cells/μL. The administration of protease inhibitors with rifampin can result in subtherapeutic blood levels of antiretroviral agents and toxic levels of rifampin. Rifabutin has fewer interactions with protease inhibitors and non-nucleoside reverse-transcriptase inhibitors. Rifabutin can be used safely and effectively with the protease inhibitors indinavir and nelfinavir or the non-nucleoside reverse-transcriptase inhibitor efavirenz. Ritonavir should not be used with rifabutin. This patient cannot stop his antiretroviral medications because his CD4 count is <350/μL.

Topic:

Pulmonary

Record # 77

Question/Fact:

A 39-year-old male warehouse employee presents to your office because of persistent pain in his lower back and feet for the past couple of months. He reports that the back pain has been persistent ever since its onset and is associated with morning stiffness. This stiffness and pain, however, improve to a great degree with movement. The foot pain is described as a burning sensation, which is constant and aggravated by walking. The patient has tried to treat his back pain with a heating pad and rest without much relief. There is no history of trauma. On physical examination, the patient is found to have significant back pain, with radiation to the lower extremities, and diffuse tenderness and a decreased range of movement in his hips and lumbar spine. Hip flexion with straight-leg raising test is negative, and there are no focal neurological deficits. There is limited motion of the lumbar spine and limited chest expansion. His past medical history is significant only for a urinary tract infection one week ago. A lumbar radiograph reveals sacroiliac joint involvement with erosions and widening at the joint space, sclerosis, and fusion. Laboratory studies show: hematocrit 31.0%, leukocyte count 6,800/mm3, erythrocyte sedimentation rate 45 mm/h. The rheumatoid factor is negative, but the HLA-B27 is positive. Urinalysis is negative for nitrates, with 5-10 leukocytes/hpf. There are few bacteria. What is the most appropriate treatment for this patient?

(A) Aspirin
(B) Naproxen
(C) Norfloxacin
(D) Intra-articular injection with glucocorticoids
(E) Referral for physical therapy with active joint manipulation and aquatic exercises

Answer:

(B) Naproxen

Explanation:

Ankylosing spondylitis is a chronic, systemic, inflammatory disease that affects the sacroiliac joints, hips, and spine. Sacroiliac joint involvement is particularly prominent in this disease, as well as paraspinal muscle spasms and tenderness over the sacroiliac joint. The onset is usually between the ages of 15 and 40. There is a male predominance. As a matter of definition, the duration is for more than three months. Morning stiffness is common, and there is improvement with exercise. Often, pain and stiffness of the thoracic region with limited chest expansion are found. Physical findings associated with ankylosing spondylitis include a symmetrically decreased range of movement, diffuse tenderness, hip involvement, negative hip flexion with straight-leg raising test, and the absence of focal neurological deficits. Laboratory findings include an elevated erythrocyte sedimentation rate, anemia of chronic disease, and the absence of a positive rheumatoid factor. Ninety percent of patients are positive for HLA-B27.

Radiographic findings include sacroiliac involvement with erosions, "pseudowidening" of joint space, and sclerosis of both sides of the sacroiliac joint. This latter finding is needed for diagnosis. There is also fusion of the sacroiliac joint. There can also be spinal involvement, such as syndesmophytes, a bamboo spine, and the squaring of superior and inferior margins of the inferior margins of the vertebral body.

Treatment for ankylosing spondylitis is initially with NSAIDs, which are used to suppress articular inflammation, pain, and spasm. NSAIDs, such as Naprosyn, indomethacin, and sulindac have shown greater effectiveness than aspirin. This would allow the patient to undergo physical therapy and rehabilitation to increase their quality of life. Few patients need intra-articular steroid therapy, except for joint inflammation that is nonresponsive to other therapy. In contrast to ankylosing spondylitis, Reiter's syndrome is a seronegative arthropathy characterized by urethritis, inflammatory eye disease, or mucocutaneous disease and is unlikely in this patient. Although he has what appears to be a urinary tract infection, there are no associated sequelae of Reiter's syndrome, such as the characteristic skin findings of keratoderma blennorrhagicum or eye findings.

Topic:

Rheumatology

Record # 78

Question/Fact:

A 42-year-old man comes to your office complaining of feeling full after eating only salad at dinner for the past three months. He has felt fatigued recently while gardening and going to the shopping mall. Physical examination reveals a mild pallor, clear lungs, no murmurs, and no cervical or axillary adenopathy. There is massive splenomegaly, and the liver edge is felt one inch below the right costal margin. There are no ecchymoses or petechiae. Laboratory studies show: WBC 140,000/mm3, with 82% neutrophils, 10% basophils, and no blasts; hemoglobin 10 mg/dL, hematocrit 30%, platelets 320,000/mm3. The peripheral smear shows a left-shifted myeloid series and bands. What is the most specific diagnostic test?

(A) Splenic aspirate
(B) Leukocyte alkaline phosphatase (LAP) score
(C) bcr-abl gene
(D) Uric acid
(E) Vitamin B12 level

Answer:

(C) bcr-abl gene

Explanation:

The diagnosis of chronic myelogenous leukemia (CML) is based on a chromosomal finding that involves a reciprocal translocation between the long arms of chromosomes 9 and 22, the latter of which is termed the Philadelphia chromosome. This finding is present in 98% of cases of CML. In cases of CML without the Philadelphia chromosome, the bcr-abl gene can be demonstrated to make the diagnosis. This is a fused proto-oncogene composed of the two pieces of chromosomes 9 and 22 that are translocated. From the point of view of common usage, patient management, and this question, the term Philadelphia chromosome and bcr-abl gene are interchangeable. CML is a myeloproliferative disease rather than a malignant leukemic process when it is initially diagnosed. Twenty-percent of cases per year transform into acute leukemia.

A high uric acid level can be seen in any disorder that gives a high turnover of cells that contain nuclei and is therefore nonspecific. The leukocyte alkaline phosphatase (LAP) will usually be low in CML but high in those patients whose white cell count is elevated as a reaction to other problems such as an infection. LAP is used to distinguish a leukemoid process from a leukemia. A low LAP score is what tells us to get the Philadelphia chromosome. Splenic aspirate has no utility in this disorder. The vitamin B12 level is characteristically elevated in CML but is not specific and is not a basis for management.

Topic:

Hematology-Oncology

Record # 79

Question/Fact:

A 63-year-old woman presents to the emergency department with confusion and mental status changes for the last two days. Her family says she has had symptoms of nausea, vomiting, abdominal pain, and diarrhea over the past few days. The patient has a history of cervical cancer, leading to clots in the legs and lungs several months prior to this admission. After a Greenfield filter was placed, she was sent home on coumadin. On this admission, she is found to be febrile with a temperature of 101.5 F orally, a pulse of 115/min, and a blood pressure of 90/60 mm Hg. Laboratory studies show: White cell count 11,000/mm3; hematocrit 31%; platelets 177,000/mm3; sodium 126 mEq/L; potassium 5.7 mEq/L; chloride 114 mEq/L, bicarbonate 22 mEq/L; BUN 33 mg/dL; creatinine 1.2 mg/dL; glucose 57 mg/dL. Prothrombin time 24 seconds; INR 2.2, aPTT 68 seconds. What would be the best initial test?

(A) Plasma renin level
(B) Cosyntropin stimulation test
(C) Serum cortisol level
(D) Lumbar puncture

Answer:

(B) Cosyntropin stimulation test

Explanation:

The sudden onset of abdominal pain, fever, hypotension, and hyperkalemia are suggestive of acute adrenal insufficiency. The presence of anticoagulation in this patient suggests the possibility of massive adrenal hemorrhage as the etiology of the acute adrenal insufficiency. The hyponatremia and hyperkalemia may be mistakenly attributed to the inhibitory effect of heparin on aldosterone synthesis when heparin is used. However, the degree of hyponatremia and hyperkalemia seen with hypoadrenalism does not occur with heparin. In this patient, major risk factors for adrenal hemorrhage include thromboembolic disease, sepsis, and hypotension.

The diagnosis of acute adrenal insufficiency secondary to adrenal hemorrhage is made by a cosyntropin stimulation test. Synthetic ACTH (cosyntropin) 0.25 mg is administered parenterally, and serum is then obtained to measure cortisol levels 30 to 60 minutes later. An abnormal test is an inadequate rise in cortisol level in response to cosyntropin. The normal response is for serum cortisol to rise at least 20 µg/dL. An undetectable level in the presence of shock strongly supports the diagnosis. However, a single normal serum cortisol level does not exclude the possibility of adrenal insufficiency. Plasma ACTH is markedly elevated if the patient has primary adrenal disease (>200 pg/mL). The diagnosis is confirmed by an abdominal CT scan that reveals hyperdense, bilaterally enlarged adrenal glands. Therapy consists of stopping anticoagulation and rapidly infusing saline with glucose and intravenous hydrocortisone to restore blood volume and pressure. Long-term therapy consists of oral hydrocortisone, although some patients require fludrocortisone (Florinef), a synthetic mineralocorticoid.

Acute adrenal insufficiency must be distinguished from other causes of shock. Hyperkalemia is also seen with hemolysis, rhabdomyolysis, the use of ACE inhibitors, and spironolactone. Both eosinophilia and lymphocytosis are characteristic of adrenal insufficiency.

Topic:

Nephrology

Record # 80

Question/Fact:

A 45-year-old man with no significant past medical history was recently diagnosed with condylomata lata at a nearby clinic. He was given a single intramuscular injection of benzanthine penicillin 2.4 million units. One hour after the injection, the patient began to feel ill while in the waiting room. He tells the doctor that he has a headache and feels flushed. He has no allergies. He feels cold and is short of breath. His blood pressure is 90/60 mm Hg, with a heart rate of 120/min, a respiratory rate of 26/min, and a temperature of 102.6 F. He has a flushed appearance. His RPR was positive at 1:128. What is the best management for this patient?

(A) Aspirin
(B) Steroids
(C) Diphenhydramine, steroids, and oxygen
(D) Intensive care unit monitoring for 24 hours
(E) Switch the penicillin to doxycycline

Answer:

(A) Aspirin

Explanation:

The Jarisch-Herxheimer reaction is a systemic reaction that occurs within 24 hours after the initial treatment of syphilis with effective antibiotics, especially penicillin. It consists of the abrupt onset of fever, chills, myalgias, headache, tachycardia, hyperventilation, vasodilation with flushing, and mild hypotension. It is common in syphilis after treatment has been started and may occur in as many as 90% of patients. It can last from 12 to 24 hours and has been correlated to the release of a heat-stable pyrogen from the spirochetes. The reaction is self-limited and can be treated with aspirin. Prednisone should be given with aspirin in pregnant woman and in those with cardiovascular or symptomatic neurosyphilis.

Topic:

Infectious Diseases


 
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