USMLE forum
 
USMLE Forum
Step 1
Step 2 CK
Step 2 CS
Matching & Residency
Step 3
Classifieds
 
Archives
 
 
  <<   < *  Step 3   *  >   >>  

* collection of previously posted questions
 #582626  
  usmle71 - 04/28/11 13:01
 
  MED 28

A 55 y/o woman with history of well controlled DM Type II presents for her regular follow-up visit. She has no new complaints. She has been well controlled on Metformin alone with a hemoglobin A1c of 6.5. The patient is afebrile with a B.P 96/72, HR 88, RR 16. Physical examination is benign except for decreased sensation in her bilateral lower extremities consistent with diabetic neuropathy and bilater lower extremity edema. Her last urinary microalbumin about one year ago was negative. A repeat dipstick test now is positive for protein and blood but negative for leucoesterase and nitrite. Subsequent urine microscopy reveals 4 dysmorphic RBCs/HPF and red cell casts. Labs reveal elevated serum creatinine at 1.4 as opposed to her baseline creatinine of 0.8 6 months ago. The next important step in approaching this patient’s Renal Insufficiency is:

A) Obtain CPK level
B) 24 hour urine for microalbumin
C) Start ACE inhibitor
D) Repeat urinalysis in 3 months
E) Referral to Nephrologist and Renal biopsy
F) Start emperic antibiotic therapy for UTI

Ans. E.

The presence of red cell casts indicate glomerular origin of this patient’s hematuria. Etiologies include various glomerulonephritis and hence, a renal biopsy is warranted. A nephrotic syndrome that is expected with Diabetic nephropathy should not have dysmorphic red cells or red cell casts in urine. Presence of these indicates Nephritis but not nephrotic syndrome.

A. is not the answer because here a positive dipstick is also followed by a positive urinalysis indicating true hematuria. A myoglobinuria will have positive dipstick but no RBCs on urine microscopy.

B. is not the answer because it does not add anything to elucidate the cause of this patient’s hematuria. In view of concomitant presence of RBC casts, this patient’s acute onset protein in the urine may be secondary to glomerulonephritis rather than DM nephropathy.

C. Presence of RBC casts indicate glomerual cause of hematuria. So, the patient should be referred to a nephrologist rather than a urologist

D. Repeating urinalysis in 3 months is appropriate for a new microscopic hematuria with out any features suggesting kidney involvement. Here hematuria is clearly glomerular in origin and requires further work up as soon as possible.

F. Is incorrect because this patient has no evidence of UTI. The patient’s clinical features as well as urinalysis findings do not suggest a UTI. The patient has no fever or dysuria. Dipstick is negative for leucoesterase or nitrite. Urinalysis has no WBCs or WBC casts. Absence of all these make UTI an unlikely etiology of her hematuria.
MED 27

25 y/o woman with hx of endometriosis, has had 2 year history of migraines, however, they bother only once or twice a month. Only one of these attacks a month makes her really disabled. She has been started on propranolol 6 months ago and has been headache free for about three months. She says she recently started oral contraceptive pills 3 months ago and her headaches have been out of control. She is getting about 3 to 4 episodes of migraines per month now but no aura. Physical exam is normal. What is the most appropriate next step in management ?

A) Discontinue Oral Contraceptive pills

B) Switch to OCPills with low dose estrogen.

C) Start prophylaxis with Topiramate

D) Switch to OC Pills with high dose Estrogen

E) Obtain MRI Brain with gadolinium

Ans. B


Oral contraceptive pills can worsen migraine but have also been shown to improve certain types of migraines such as Menstrual migraines. Hence, patients may report variable response in the intensity of migraines after starting OCPills.

In our case above, OC pills are clearly responsible for worseing of her Migraine. However, they were started in hercase for a reason – she has Endometriosis and also, desires contraception! Hence, benefit vs. risk should always be weighed in making treatment decisions like this.

Often, estrogen component of the OCP is responsible for worsening headaches. So, switching to low dose estrogens should be the first step and it often improves the situation.

The question also tests the concept of risk factors for stroke. Migraines with aura is a known risk factor for stroke but migraines with out aura are benign. OC pills are an independant risk factor for stroke. Hence, OC pills should not be started in any patient with increased risk of stroke ( eg: severe hypertension, smoking, migraine with aura etc).

Key Concept : Migraines in the above patient are with out aura. So, OC pills need not be discontinued. Reducing the dose of estrogen component should be the next step in management.
MED 29
A 45 y/o woman presents to the Emergency room with complaints of severe flank pain and nausea. Patient’s past medical history reveals chronic smoking and occupational exposure to aniline dyes. Physical examination reveals mild right costo-vertebral angle tenderness. The patient is afebrile. Labarotory investigations reveal urine dipstick positive for blood but negative for leucoesterase and nitrite. Urinalysis reveals numerous RBCs per HPF. There are no RBC casts or WBC casts. Urine HCG is negative. The next step in managing this patient’s condition is:

A) Start intravenos antibiotic therapy
B) Non Contrast CT scan
C) Contrast enhanced CT Scan
D) CT urogram and Cystoscopy
E) Ultrasonography

Ans. B

This patient’s clinical features as well as hematuria on urinalysis suggest renal colic from possible urolithiasis. Non Contrast CT is the best and first imaging test of choice in evaluating renal calculi ( do not choose plain x-rays or ultrasound. Ultrasound is optimal only in pregnant patients). The patient is at risk for bladder cancer however, her current symptoms of acute painful hematuria suggest a renal colic not a bladder malignancy.

A. is not correct as this patient has no evidence of pyelonephritis or UTI ( absent wbc casts, absent wbcs or fever, no leucoesterase or nitrite on dipstick).

C. is incorrect because CT urogram involves administration of contrast after a initial non contrast study. A non contrast CT is sufficient in most cases to evaluate the presence of stones ( except Indinavir stones in HIV positive patients on HAART where a contrast CT is preferred). Cystoscopy is not needed as acute flank pain with hematuria in this patient favors renal calculus more than a bladder cancer.

D. IVP is incorrect since non contrast CT is the best test to visualize the stones.

E. is incorrect because Non contrast CT is better than ultrasound in visualizing the renal calculi
MEDQ26

Sam is a 35 y/o alcoholic who is brought to the ER in a comatose state. Sam’s wife tells you that she had an argument in the evening about 5 hrs ago over Sam’s alcohol habits. Sam apparently got mad over the discussion, drove his car and returned an hour ago in a very intoxicated state. Wife called the EMS and rushed him to the ER. On examination Sam is disoriented and hallucinating , Pulse 120 Tm 99, RR 26 BP 126/76. The rest of the physical exam is normal except for stuporos state and alcohol smell. Lab studies revealed Na 130 k 3.4 cl- 95 Hco3 16, Glucose 90 Creatinine 1.6 BUN 45. Blood Ethylalcohol level was 180. Serum osmolarity was 360mg%. ABGs revealed 7.28, Pco2 28, Po2 76 Sao2 93. The next best step in management ?

A) Endotracheal intubation in view of severe acidosis
B) Hemodialysis because this is an acute renal failure causing acidosis
C) Fomepizole because of suspicion of ethylene glycol intoxication
D) Supportive treatment for now because this is an ethylalcohol induced lactic acidosis
E) Bicarbonate drip to reverse the acidosis because this is renal tubular acidosis

Answer C

fomepizole is the inhibitor of alcohol dehydrogenase and is the antidote for suspected ethylene glycol poisoning. Ethylene glycol poisoning in this case can be diagnosed by the prolonged Osmolar gap which can not be explained by high ethyl alcohol level alone.

MED Q12
A 24 y/o athlete presents to your office with complaints of reddish discoloration of urine. He claims that he has been exercising and running vigorously for the past two days. He is very determined to lose the extra weight that he has put up in the recent months and has been fasting in the nights for the past one week. His past medical history is significant for two abdominal surgeries which included laparotomy and appendicectomy in the past for intermittent severe abdominal pain. The patient does not smoke but does occassional consumes alcohol in binges. He did involve in one such alcohol binge last night. Physical examination is benign except for decreased power and reflexes in bilateral lower extremities. There is no rash. His urine specimen was grossly red in color. Urine dipstick was negative for protein, blood, leucoesterase and nitrite. Urine microscopy did not reveal any RBCs, WBCs or Casts. Serum creatinine and complete blood count are with in normal limits. A Creatinine Phosphokinase ( CPK) level has been ordered but is not yet available. The most likely cause of this patient’s grossly red urine is :

A) Rhabdomyolysis
B) Paroxysmal Nocturnal Hemoglobinuria
C) Acute Intermittent Porphyria
D) Await CPK level for correct diagnosis
E) Glomerulonephritis

Ans.C

Reddish discolration of urine with a negative dipstick for blood suggests that this red color is not from either a pigment globin ( hemoglobin or myoglobin) or a Red blood cell ( Hematuria). Such red colored urine with negative dipstick can be seen with drugs such as Rifampin, foods such as beets and substances like porpyrins in urine.

This patient also has sensory as well as motor neuropathy in his lower extremities, a typical manifestation of Acute intermittent porpyria attacks. The presence of peripheral neuropathy in patients with history of recurrent abdominal pains should raise the suspicion of Acute Intermittent Porphyria ( AIP). This patient had several severe abdominal pain episodes which were misdaiagnosed as appendicitis and he even underwent a futile laparotomy. Patients are pain free between the attacks. Fasting and drugs like phenobarbital, alcohol can precipitate AIP attacks. Unlike other porphyrias, rash is not typically seen in AIP.

A. is not the answer because dipstick would be positive for blood in rhabdomyolyisis
B. is not the answer because dipstick would be positive in hemoglobinuria
D. is not the answer since the diagnosis of reddish urine here is not in favor of myoglobinuria.
E. a negative dipstick and negative microscopic urinalysis rules out gross hematuria as a cause of this red urine
F. Negative dipstick for blood, negative urine microscopy and absence of RBC casts rule out glomerulonephritis as a cause of this patient’s red urine

Q9

A 26 year old woman presents to the ER with generalized weakness associated with perioral numbness. She is moderately built and looks slightly depressed. On physical exam, she has mild pallor. She denies use of any medications. BP 120/88 mmHg and physical exam is normal. Lab data: Cr 1.2mg/dL, BUN 15mg/dLNa 136 , K 2.8 , Cl 88 , HCO3 38. Urine Na 45 meq/L, Urine K 35 meq/L, Urine Cl 8 meq/L, Urine specific gravity 1.010, Urine pH 7.

Most likely diagnosis is :

A)Laxative Abuse

B)Surreptious vomiting

C)Licorice abuse

D)Malabsorption Syndrome

E)Hyporeninemic Hypoaldosteronism

q21) Most appropriate next step in the management:

A)IV normal saline

B)Spronolactone

C)Amiloride

D)Psychiatry consult

E)Reassurance because this is self limiting

Ans. B
Ans. A

Key concepts : Recognize the etiologies of metabolic alkalosis. Understand the concept of urinary chloride level in identifying the etiology of metabolic alkalosis. If urinary chloride is less than 10meq/L, it indicates Saline responsive alkalosis. A higher than 10 value indicates Saline resistant alkalosis.

Ans. B is the correct choice because the patient has hypokalemic, hypocholremic metabolic alkalosis. Urinary chloride less than 10 indicate that this is a saline responsive metabolic alkalosis and hence, should be treated with IV normal saline. NS can correct this metabolic alkalosis.

Ans. A incorrect because diarrhea due to laxative abuse should cause non anion gap metabolic acidosis.

Ans. C is incorrect. The active component in licorice is glycyrrhizic acid which inhibits 11B-HSD2, the enzyme that inactivates cortisol to cortisone in the collecting duct. Inhibition or deficiency of 11B-HSD2 causes cortisol to remain active and like aldosterone, cortisol binds to aldosterone receptors causing hypokalemia, metabolic alkalosis and low-renin and low-aldosterone hypertension. This is not licorice abuse because this patient does not have hypertension. Also, urinary chloride will be higher than 10 in licorice induced metabolic alkalosis

Ans. D is incorrect because it should cause chronic diarrhea and non-gap metabolic alkalosis.

Ans. E is incorrect because hyporeninemic hypoaldosteronism causes hyperkalemia and metabolic acidosis
( Type IV RTA)
MED Q18

A 76 year old debilitated man with history of advanced dementia lives in an extended care facility. He has a history of recurrent Urinary tract infections which develop every six months with mild fever, frequency of micturition and urinary incontinence. In the past, his urine cultures revealed E.coli > 100,000 colonies on several occassions. He has no indwelling Foley catheter and he is only placed on diapers. His vital signs are temperature of 98.6, HR 88, RR 18 and a BP of 130/84. A nurse practioneer has routinely ordered a urinalysis which revealed positive leucoesterase and nitrite. This was followed by a urine culture that revealed 100,000 colonies of E.coli. The nurse is concerned about this finding and calls you for appropriate management.
What is the appropriate treatment?

A. Cystoscopy and Intra-venos pyelogram
B. Continuous low dose antibiotics for prevention of recurrent UTIs
C. Catheterize and irrigate the Bladder daily
D. Intravenos antibiotics with broad spectrum coverage
E. No need of treatment as this is colonization
Ans. E.

Key Concepts : Recognize the definition of "Recurrent" UTI . Recognize the difference between "colonization" and "Active Infection"

Answer. E No need of treatment is the correct choice because this old man has no signs of active infection at this time. He has no fever or tachycardia or any signs of sepsis or infection.

Ans. A is incorrect. Cystoscopy and IVP can be performed to evaluate the urinary tract if the patient had severe UTI or recurrent UTI. It is not the appropriate step at this time.

Ans. B would be appropriate as a prophylactic therapy if the patient has Recurrent UTI. Understand that the Recurrent UTI is defined as 2 or more episodes in past 6 months or 3 or more episodes in past one year. This patient does not meet the criteria of recurrent UTI since he suffers only one episode every 6 months.

Ans. C is not helpful in preventing UTI and is also, not appropriate step at this time. Indwelling catheters may in fact, increase the risk of UTIs.

Ans. D would be appropriate if the patient had severe UTI. He has no signs of acute infection at this time.

MED Q21
A 30 y/o pregnant woman has a one week history of a slowly enlarging red lesion on her right thigh. She reports having gone on a camping trip about 3 weeks ago and now recalls that she removed a tick from the site of the lesion. An ELISA test is negative for Lymes. Upon further questioning, she also reports contact with poison Ivy like bushes during the same camping trip

What is the next step?
A. Re-assurance
B. Ampicillin
C. Doxycycline
D. Western blot testing for Lymes
E. Topical Corticosteroid

Ans. B

Ampicillin ( Ans.B) is the most appropriate antibiotic for this pregnant woman with early stage Lymes disease. The patient has erythema chronicum migrans which is pathognomonic of early lymes disease. ELISA may be negative in early stage LYME disease and diagnosis must be based on clinical history. No further testing is necessary in the presence of such strong clinical history.

Ans. A is inappropriate and not treating lyme disease can be lethal to the patient.

Ans. C is an appropriate first choice for non pregnant patients with lyme disease. Doxycycline is classified as pregnancy category D. Tetracycline exposure during the second or third trimester can cause permanent discoloration of the teeth.

Ans. D is incorrect. Western blot is only used to confirm a positive ELISA test because ELISA is associated with a high rate of false positive results. In the absence of strong clinical suspicion, both ELISA and Western blot must be positive in order to diagnose lyme disease. Such testing is especially useful when someone is suspected to have late lyme disease manifestations. ELISA in this patient is negative. It is not required in this case to diagnose early lyme disease given that she has strong clinical features to support the diagnosis.
MED Q11
A 55 y/o man presents with shortness of breath on exertion. Laboratory studies reveal iron deficiency anemia. Patient was started on Iron pills orally. The patient consumes a lot of red meat and was surprised to know that he was iron deficient. Fecal occult blood testing revealed a positive stool guaic. A colonoscopy and EGD were subsequently performed which were absolutely normal. A repeat Guaic was performed and was found to be negative. A further investigation for the cause of iron deficiency in this patient revealed celiac disease leading to iron malabsorption. What is the most likely cause of positive Guaic in this patient? •

A. Obscure GI Bleeding

B. Celiac disease

C. False positive from red meat

D. False positive from Iron pills

E. Colon cancer

Ans. C

Red meat can lead to false positive guaic as it may oxidize the guaic reagent ( Vitamin C on the other hand, anti-oxidizes it and causes false –ve guaic.)

Obscure bleeding ( Ans. A) is possible but in this patient the most likely cause for iron deficiency was already established as celiac disease making intermittent obscure bleeding less likely.

Celiac disease ( Ans. B) does not cause False +ve Guaic.

Iron pills ( Ans. D) can cause black discoloration of the stool but not a false positive guaic.

The fact that the colonoscopy was normal makes bleeding from colon cancer ( Ans. E)unlikely here.
MED Q25

A 46 y/o woman who is a school bus driver by occupation presents to your office for regular follow up. She has a history of ADPKD. Her blood pressure is well controlled at 120/70 on enalapril. She has no other problems. She denies any headache. There is no family history of intracranial or subarachnoid hemorrhage. However, she is concerned that her head might explode because her sister who also has ADPKD was recently diagnosed of having a berry aneurysm. She wants to be screened for berry aneurysm as soon as possible. Her physical examination is benign and does not reveal any focal neurological deficits. Which of the following suggests the necessity for screening in her case?

A. Family history of berry aneurysm

B. Polycystic kidneys

C. School bus driving

D. Cysts in the liver

E. No screening necessary in her case

Answer. C

High risk jobs ( pilot, bus driver etc) is one of the indications to screen for berry aneurysm in asymptomatic ADPKD patients. Family hx of berry aneurysm (Ans. A) alone does not warrant screening for berry aneurysm in asymptomatic ADPKD patients. Asymptomatic ADPKD patients must be screened if there is a family history of “Ruptured” berry aneurysm ( history of SAH in the family etc)
E. is not the answer because this patient is a school bus driver by occupation and needs to be screened.

Key Concepts

Screening for Berry Aneurysms:

- MRA of head – recommended screening test to detect berry aneurysms.

- Screen only if
- family history of subarachnoid hemorrhage ( Family hx of a ruptured berry aneurysm) not just a family history of berry aneurysm.
- Patients with with high risk jobs (pilots/ bus-drivers) - an event during such a job is a risk to other’s safety as well.
- Patients with symptoms suggestive of a berry aneurysm
( severe headache, focal neurological deficits)

PEDI 2,3
Q12) A 12 y/o boy is brought to you by his mother for skin rash and complaints of intermittent abdominal pain, joint pains for past 2 days. He did have an upper respiratory infection about 2 days ago. On physical exam, his vitals are normal. Abdomen is benign with out any tenderness or rigidity. However, you notice patchy purple discolorations on his extremities and the back. Lab studies are obtained that revealed

WBC: 6.6 , HGB: 15.3 , MCV: 88 , Platelets: 290,000 ( normal 180k to 400k)
BUN: 11 , Creatinine : 0.6 ( normal) , Anti streptolysin O titer : negative
Streptozyme : negative ,Urine dipstick : normal without any blood
Urinalysis : normal/ no rbcs/ no protein
The mother is very anxious and asks about the long term prognosis of her son. Your response :

A) Reassure the mother that boys disorder is self limiting and does not require any follow up
B) Tell her the boy needs to be admitted and treated vigorously to prevent renal failure
C) Tell her that renal failure develops 100% of such cases and hence needs very cautious follow up
D) Tell her that 50% of such cases progress to end stage renal disease.
E) Tell her that the boy requires follow up monthly urinalysis for at least 3 months in order to make sure there is no heamaturia/ renal dysfunction.

Q13) If the boy presented with Renal failure in the above case, the most likely underlying pathology would be :
A) IgA mediated vasculitis
B) Post streptococcal glomerulonephritis
C) Anti GBM disease
D) Acute tubular necrosis
E) Interstitial Nephritis

Answers : E and A

E) Tell her that the boy requires follow up monthly urinalysis for at least 3 months in order to make sure there is no heamaturia/ renal dysfunction - is the correct answer.

The patient has non thrombocytopenic purpura associated with abdominal pain and arthralgias. These features are consistent with the diagnosis of Henoch Schonlein Purpura
( HSP). The initial episode of HSP usually resolves within one month. Renal impairment may be seen at the first presentation. However, some children may manifest with late renal disease. In children with no renal impairment at presentation, Urinalysis and blood pressure monitoring should be followed monthly for three months after presentation. In children presenting with renal involvement at the first presentation, should be followed more carefully i.e; urinalysis every week for first 2 months and then every month for one year. Patients with persistent proteinuria, hypertension, or renal insufficiency should be referred to nephrology for further evaluation and treatment.

Choice A is incorrect because though the disease is self limiting, it needs to be followed for possible development of renal impairment.

Choice B is incorrect - no admission required because the boy has an initial mild attack of HSP with out any renal impairment at this time.

Choice C is incorrect because renal impairment may be seen only in about 20 to 50% cases of HSP. Renal involvement is typically seen with in one month of onset of systemic symptoms.

Choice D is incorrect because only 2 to 5% patients progress to End Stage Renal Disease
MED Q23
A 65 y-old male undergoes a screening colonoscopy which reveals a 2cm polyp. The histopathology reveals an adenomatous polyp with no atypical cells. The most appropriate follow up for this patient is :
A) Colonoscopy at 10 yrs
B) Colonoscopy at 5 yrs and then every 5 yrs
C) Colonoscopy at 3 yrs and then every 10 yrs
D) Colonscopy at 3 yrs and then every 5 years
E) CEA every 3 months

Ans. D
The polyp is adenomatous and is large > 1cm ( intermediate risk).


surveillance colonoscopy after polyp removal should be based on the risk.
It gives classification of risk as

a) Low Risk: - 1 to 2 adenomatous polyps, both small < 1cm
In this low risk, repeat colonoscopy in 5 years . If this is normal, repeat every 10yrs
( remember 5,10)

b) Intermediate Risk : 3 to 10 small adenomatous polyps or
any one adenomatous polyp >1cm or any adenoma with villous features or high grade dysplasia
In this group, repeat Colonoscopy in 3 years. If this is normal or shows only small polyps, repeat colonoscopy every 5 years ( remember 3, 5)

c) High risk:
- Greater than or equal to 10 adenomatous polyps, colonoscopy at 1 year.
- Sessile adenomatous ployp that are removed in pieces --> colonoscopy in 3 to 6 months to ensure that it is completely removed
- Polyp removed in total and has carcinoma insitu with clear margins --> colonoscopy at 1 year and then at 3 years and then, every 5 years ( Remember 1,3 and 5)
MED Q1

A 45 year old woman presents to your clinic with history of intermittent epistaxis. Of late, this has become more frequent. The patient has a history of atrial fibrillation for which she has been taking aspirin as recommended by her cardiologist. She has no other past medical history. The patient also takes over the counter medications such as Vitamin b-complex which she thinks keeps her from getting tired. She says she also takes about 4 grams of Omega 3 fatty acids to keep “her heart healthy” and Ginkgo biloba to slow the “ageing of her brain”. Her laboratory tests reveal normal complete blood count. Prothrombin time and partial thromboplastin time are with in normal limits. Which of the following is your next step in managing this patient’s recurrent epistaxis?

A. Advise her to discontinue omega 3 fatty acids.
B. Discontinue Aspirin
C. Advise her to stop both Omega 3 fatty acids and Ginkgo biloba
D. Advise her to stop Ginkgo biloba
E. Advise her to stop Vitamin B-complex
Ans. C

Advise to discontinue both omega 3 fatty acids and ginkgo biloba ( Ans. C). Ginkgo biloba potentiates aspirin by increasing the bleeding time. Omega 3 fatty acids in large doses can also prolong the bleeding time by decreasing the platelet aggregation. Since this patient is having recurrent epistaxis, it is advisable to discontinue both of them at this time and observe.

Ans. A is sub-optimal management.

Ans. B is incorrect. The patient has "lone" atrial fibrillation and she requires aspirin to reduce her stroke risk.

Ans. D is sub-optimal management.

Ans. E is incorrect. B-complex has no effect on bleeding time or platelet aggregation.

MED Q19

A 65 y/o man with history of chronic smoking and COPD presents for follow up visit in your office after being discharged from the hospital about three weeks ago. The patient was admitted and treated in the hospital for community acquired pneumonia and COPD exacerbation. During his hospital stay he was noted to have microscopic hematuria on routine urinalysis. The patient denies any symptoms now. His COPD is well controlled on tiotropium inhaler. His allergies include Isoniazid and Penicillin. Past medical history is significant for a positive PPD test ( latent tuberculosis) for which he has been on treatment with Rifampin for past three months. Physical examination is benign. Labarotory investigations reveal a normal CBC and serum creatinine. Dipstick is positive for blood. A repeat urinalysis during this visit reveals persistent microscopic hematuria with 3 RBCs/HPF. A urine cytology has been sent. The next appropriate step in evaluating this patient’s hematuria is:

A) Repeat urinalysis in 3 months
B) Urine cultures
C) Intravenos pyelogram
D) CT urogram and Cystoscopy
E) Stop Rifampin

3. Ans. D
This patient has significant microhematuria defines as 3 0r more RBCs/HPF established on two occassions. He also has high risk factors for having a bladder cancer or urological malignancy. So, both upper tract imaging in the form of CT urogram as well as bladder visualization in the form of cystoscopy are warranted in this patient.

A. is incorrect because the patient already had >3RBCs/HPF on two occassions already establishing the diagnosis of significant microhematuria.

B. is incorrect because this patients has no symptoms or lab findings suggesting UTI.

C. is incorrect because this patient is a high risk patient and requires both upper tract imaging as well as cystoscopy as an initial protocol. IVP is good for upper urinary tract imaging but does not adequately visualize the bladder. More over, recent recommendations favor CT urogram over IVP for upper tract imaging.

E. is incorrect. Rifampin causes red colored urine but does not cause positive dipstick or hematuria
MED Q22
A 46-year-old fisherman and Vietnam veteran presented with a recurrent rash on his arms and legs and a painful, swollen area on his left leg of several days’ duration. The rash had been a problem for about two years and was treated with several courses of antibiotics for cellulitis. The patient reported that for the past two years his skin had been prone to blister and tear with minor trauma and that at times his urine appeared to be dark reddish in color. On examination, he had a slight fever and an area of cellulitis on his left leg. His face was erythematous. On his hands, arms, and legs were vesicles and small bullae, some crusted lesions, and hypopigmented and hyperpigmented macules. What is the most important next step in diagnosis?

A. ANA

B. Rheumatoid factor

C. Skin biopsy

D. Hepatitis C serology

E. Hepatitis B serology



Ans. C



PCT is due to a defective enzyme (uroporphyrinogen decarboxylase) in liver . ( the enzyme is involved in hem synthesis)
PCT begins in mid-adult life especially after exposure to substances that increase the production of porphyrins (precursors of haem) in the liver such as alcohol, estrogen e.g. oral contraceptive, hormone replacement or liver disease
Clinical features include Sores (erosions) following relatively minor injuries, Fluid filled blisters (vesicles and bullae) and Increased sensitivity to the sun
Characteristically, the urine is darker than usual, with a reddish or tea-coloured hue

If asked on the exam, consider the diagnosis of Hepatitis C infection ( important association).

DX – Elevated urinary porphyrins, wood’s light on urine gives marked fluorescence

RX
Avoid alcohol
Use tanning creams in sun and avoid sun in acute flare.
Discontinue estrogens
Therapeutic phlebotomy to reduce iron stores (this improves heme synthesis disturbed by ferroinhibition of UROD. )
In patients in whom phlebotomy is not convenient or is contraindicated and in those who have relatively mild iron overload --> use oral chloroquine phosphate (or ) hydroxychloroquine sulfate
MED Q4,5,6,7
Q15) A 25 y/o male comes to your office with complaints of dark red colored urine and pain in the legs that started this morning. He has been working out at the local gym excessively for the past three days. He does consume alcohol on weekends but reports having involved in a binge drinking episode that included 10 beers yesterday. On physical examination, he weighs 70kg and he has some tenderness in his calf muscles which he attributes to the excessive squats he performed yesterday. Urine dipstick reveals large blood. If this patient develops acute renal failure , the most likely mechanism would be:

A) Interstitial nephritis due to pigment
B) Glomerulonephritis
C) Acute Tubular necrosis due to pigment deposition
D) Acute Tubular Necrosis due to Ischemia
E) Alcohol related direct toxic injury

q16) Lab studies revealed normal electrolytes and normal creatinine but a CPK of 50,000. His Urine output has been at 70 ml/hr for the past 6 hours. Your first step in the management to prevent development of patient’s Acute Renal Faliure :

A) Intravenos Fluids
B) Furosemide
C) Calcium Gluconate
D) No treatment because serum creatinine is normal
D) Sodium Bicarbonate

q17) The above patient has been adequately treated but his repeat CPK after 2 days is still elevated at 48,000. He complains of increasing pain in his left leg and some tingling and pricking sensations. On examination his left leg was mildly swollen and there was pain on passive stretching of the leg muscles. Dorsalis pedis and posterior tibial pulses are intact. The most likely diagnosis at this time:

A) Deep Vein Thrombosis
B) Cellulitis
C) Compartment Syndrome
D) Edema due to renal failure
E) Congestive Heart Failure

q18) The immediate course of treatment in this condition would be :

A) Anticoagulation with Heparin
B) Antibiotics
C) Emergency Fasciotomy
D) Loop diuretics
E) Elevation of the leg

Answers : C, A, C, C


Increased CPK and leg pain indicate rhabdomyolysis precipitated by alcohol and heavy exercise. Presence of blood on the Dipstick with out RBC or RBC casts indicate that this is a pigment such as myoglobin. The mechanism of renal failure in rhabdomyolysis is pigment deposition in tubules ( Toxic ATN)

Though creatinine is normal, rhabdomyolysis can lead to rapid renal failure if not adequately treated. Aggressive IV hydration is helpful in preventing renal failure. There is no role for diuretics or sodium bicarbonate.

Rhabdomyolysis leads to myoglobin release in to the tissues leading to accumulation of fluid in the comparments. Increased compartment pressure may lead to compartment syndrome and this can be llimb threatening if it is not treated with Emergent Fasciotomy
ETHIC 3
A 6-year-old with a fractured forearm is brought to the emergency room by her baby-sitter. Both the baby-sitter and emergency room staff have attempted to reach her parents to get their consent for treatment without success.

Most appropriate next step:

A) Await for the parents to call back
B) Keep trying to reach the parents
C) Refer to ethics committee
D) Take a consent from patients baby sitter before treatment
E) Get an x-ray of the forearm and treat the fracture appropriately

Ans. E

The questions says the patient is in "Limb threatening" situation.
Children less than 18 yrs are minors and are legally incompetent. Parents cannot withhold life or limb saving treatments from their children.
If they refuse, use following protocol
1. Immediate emergency - treat
2. Not immediate , but still critical - refer to ethics committee or seek court intervention. The child is declared a ward of the court and court grants permission. Eg:- juvenile diabetes
3. Not life or limb threatening - listen to parents.

Child's refusal is irrelevant unless patient is an emancipated minor
MED Q24

A 75 year old woman was diagnosed with Stage II breast cancer one year ago. The patient received chemotherapy, underwent modified radical mastectomy and radiation. . The cancer was ER+, PR+ and Her2-neu negative. The patient has been receiving Tamoxifen for the past few months. She reports that she has been experiencing vaginal spotting and intermittent mild vaginal bleeding over the past few months. She has also been experiencing intermittent hot flashes after starting Tamoxifen therapy. On physical examination, her vitals are with in normal limits. Pelvic examination does not reveal any gross pathology. Next step in managing this patient:
A. Stop Tamoxifen
B. Start oral progesterone
C. Obtain endometrial biopsy
D. Do a hysterosalpingogram
E. Recommend Hysterectomy with bilateral oophorectomy

Ans. C
Obtain Endometrial Biopsy

Tamoxifen is a selective Estrogen Receptor Modulator. It acts as an antagonist on the breast but acts like an agonist on the endometrium. Hence, Tamoxifen is used in breast cancer therapy but it also, increases the risk of endometrial hyperplasia and endometrial cancer.

Vaginal bleeding is a less common adverse effect with Tamoxifen and is usually, benign. However, when a post menopausal patient on Tamoxifen develops vaginal bleeding, endometrial biopsy ( Ans. C) must be performed at least initially to exclude malignancy.

Stopping Tamoxifen ( Ans.A) may stop bleeding if it is tamoxifen related adverse effect but it will not clarify whether the cause of the bleeding in benign or malignant.

Oral progesterone ( Ans.B) is the treatment for benign endometrial hyperplasia and will help prevent vaginal bleeding from benign hyperplasia. It is not yet clear if this patient's vaginal bleed is secondary to benign hyperplasia until a biopsy is performed.

Hysterosalpingogram (Ans.D) may reveal the pathology such uterine masses but will not provide tissue diagnosis.

Hysterectomy with bilateral salpingo-oophorectomy ( Ans.E) is too aggressive measure at this time. It can be recommended if the patient has biopsy proven early stage endometrial cancer
MED Q2
A 50 year old woman with history of coronary artery disease and hypertension presents to your office for regular health check up. The patient is compliant with her medications which include aspirin, atorvastatin and enalapril. Her blood pressure is 110/70. Laboratory investigations including CBC and comprehensive metabolic panel are with in normal limits. A fasting lipid panel that was performed one week ago reveal an LDL cholesterol of 65, HDL of 50 and Triglycerides of 150. You discuss the results with her and you inform her that the goals of therapy are being adequately met. She seemed happy to know about the results but tells you that lately, her mood has been slightly low. There are good days but she tends to have frequent bad days as well. She enjoys surfing as she used to before. She has no weightloss and her appetite is good. She denies any suicidal ideations. She asks you if there is any medication that would benefit her heart and also, help her mood. The next best step in managing this patient is :

A. Start escitalopram
B. Start clozapine
C. Refer to psychiatrist
D. Start Omega 3 Fatty Acids
E. Start St.John’s Wort



Ans. D

Omega 3 fatty acids are useful in improving the risk of coronary artery disease. Omega 3 fatty acids are also effective in reducin serum triglycerides and improves mood in mild to moderate depression. This is the medication that will help address " her heart issues as well as her mood."

Choice. A is incorrect because the patient does not have significant depression that warrants pharmacotherapy at this time. Escitalopram also does not have any beneficial effect on cardiovascular risk.

Choice. B is incorrect because the patient does not have pychotic depression that warrants clozapine at this time. Clozapine also increases cardiovascular risk by causing obesity, metabolic syndrome and worsening hyperlipidemia.

Choice. C is incorrect because the patient does not have significant depression that warrants psychiatry referral at this time.

Choice E is incorrect. St.John's wort is useful in treating mild to moderate depression. However, St.John's wort has no effect in improving the patient's cardiovascular risk.
MED 13
A 45 y/o woman presents to the Emergency room with complaints of severe flank pain and nausea. Patient’s past medical history reveals chronic smoking and occupational exposure to aniline dyes. Physical examination reveals mild right costo-vertebral angle tenderness. The patient is afebrile. Labarotory investigations reveal urine dipstick positive for blood but negative for leucoesterase and nitrite. Urinalysis reveals numerous RBCs per HPF. There are no RBC casts or WBC casts. Urine HCG is negative. The next step in managing this patient’s condition is:



•A) Start intravenos antibiotic therapy
•B) Non Contrast CT scan
•C) Contrast enhanced CT Scan
•D) CT urogram and Cystoscopy
•E) Ultrasonography

Ans. B

This patient’s clinical features as well as hematuria on urinalysis suggest renal colic from possible urolithiasis. Non Contrast CT is the best and first imaging test of choice in evaluating renal calculi ( do not choose plain x-rays or ultrasound. Ultrasound is optimal only in pregnant patients). The patient is at risk for bladder cancer however, her current symptoms of acute painful hematuria suggest a renal colic not a bladder malignancy.

A. is not correct as this patient has no evidence of pyelonephritis or UTI ( absent wbc casts, absent wbcs or fever, no leucoesterase or nitrite on dipstick).

C. is incorrect because CT urogram involves administration of contrast after a initial non contrast study. A non contrast CT is sufficient in most cases to evaluate the presence of stones ( except Indinavir stones in HIV positive patients on HAART where a contrast CT is preferred). Cystoscopy is not needed as acute flank pain with hematuria in this patient favors renal calculus more than a bladder cancer.

D. IVP is incorrect since non contrast CT is the best test to visualize the stones.

E. is incorrect because Non contrast CT is better than ultrasound in visualizing the renal calcu

PEDI 2
A 7-year-old boy is brought to the emergency department by his mother because of “tea-colored urine” for the last several days. He has also had some nausea and vomiting, and his eyes appear swollen when he wakes up in the morning. The eye swelling tends to resolve over the course of the day. He is generally very healthy and there is no family history of any chronic diseases. His temperature is 36.7 C (98.0 F), blood pressure is 130/90 mm Hg, pulse is 96/min, and respiratory rate is 16/min. Physical examination is unremarkable. A urinalysis shows red cell casts. At this time the most appropriate study to confirm your diagnosis is

A. antinuclear antibody
B. antistreptolysin O antibody
C. renal biopsy
D. renal ultrasound
E. urine culture

The correct answer is B. Poststreptococcal glomerulonephritis is the most common cause of acute glomerulonephritis in children. It usually follows a streptococcal pharyngitis by 1-2 weeks and a streptococcal skin infection by 2-3 weeks. It most commonly occurs in school-age children and has a male to female predominance of 2:1. It is most commonly characterized by hematuria (microscopic or gross) with red cell casts, proteinuria, hypertension (from fluid overload secondary to decreased glomerular filtration rate), and edema (from retention of salt and water). Laboratory values are usually significant for markedly decreased complement levels (C3 and C4), hypo- or hypernatremia, and a blood urea nitrogen elevated disproportionately to the creatinine. In order to diagnose poststreptococcal glomerulonephritis with certainty, there needs to be evidence of a preceding streptococcal infection such as an elevated ASO or streptozyme.
Systemic lupus erythematosus (SLE) nephritis is another cause of hematuria. If this child had persistently low complement levels, an ANA (choice A) would be indicated as one of the first screening tests for SLE. Keep in mind that only 25% of cases of SLE are diagnosed within the first two decades of life, the male-to-female ratio is 1:8, and renal disease is not present in all cases of SLE. Therefore, it is unlikely that this 7-year-old boy has new onset SLE, and other more common causes of glomerulonephritis must be ruled out first.
At this time, a renal biopsy (choice C) is not indicated. A renal biopsy is an invasive procedure with inherent risks. As this patient fits the perfect description for post streptococcal glomerulonephritis a renal biopsy would only be indicated if the complement level does not return to normal within 8 weeks, and the gross hematuria does not resolve over several weeks. If one was to do a renal biopsy on a patient with post-streptococcal glomerulonephritis, the findings would be: mesangial and capillary cell proliferation, inflammatory cell infiltration, and granular "humps" of IgG and C3 below the glomerular basement membrane.
A renal ultrasound (choice D) is useful in evaluating parenchymal disease, urinary tract abnormalities, or renal blood flow. In the case of post-streptococcal glomerulonephritis, the changes are microscopic and therefore would not be seen on ultrasound.
Urinary tract infections are a common cause of hematuria. Therefore, it is a good idea to do a urine culture (choice E) in all cases of hematuria. Unfortunately, the child in this case has red cell casts which indicate the kidneys are the source for the blood. So, although a urine culture should be sent on this child, it will probably not help with the diagnosis.

MED 16
A 55 year old man was recently found to have a 2.0 cm thyroid nodule on palpation during his annual physical. An ultrasound revealed no suspicious features of malignancy. TSH and free T4 levels were normal. Patient denies any history of neck irradiation, pain, dysphagia or hemoptysis. There is no history of cancer in his family. The next best step in evaluation of the nodule :

A. Suppressive therapy with levothyroxine

B. FNAC

C. Lobectomy with isthmectomy

D. Observation

E. Radio iodine therapy

PICK B

ETHICH Q 2

9 year old girl is brought to the ER for a foot infection which looks serious. She needs IV antibiotics and debrideent, or you know that her foot is in danger of amputation. The mother refuses consent for antibiotics and debridement. You discuss the need for immediate treatment and the risks in the presence of a witness. But mother still refuses the treatment. Your next step:

1) order the antibiotic and the debridement, overruling the mother.
2) Get an emergency court order
3) get an emergency ethics consult
4) agree with the mother and not give the treatment

PICK A,

MED 14,15

46. A 55-year-old man presented for a regular follow-up to your office 2 weeks ago at which time a palpable nodule of 1.7 cm was noted in the left thyroid lobe. He denies a history of head and neck irradiation, hoarseness, pain, dysphagia, or hemoptysis. His physical exam is otherwise normal, with no lab abnormalities. Most appropriate next step in management?

A. Ultrasound of thyroid

B. TSH level

C. Fine Needle Aspiration ( FNAC)

D. Observation

E. Suppressive therapy with levothyroxine

47. The patient in Q1. subsequently, underwent an FNAC which revealed Papillary Carcinoma of thyroid. Staging work-up revealed no evidence of distant metastases and a neck CT scan does not reveal any lymphadenopathy. The most appropriate management of his thyroid cancer involves:

A. Radio iodine therapy ( RAI)

B. Partial thyroidectomy

C. Total thyroidectomy

D. Life long levothyroxine + Total Thyroidectomy + RAI therapy

E. Total Thyroidectomy + Life long levothyroxine

F. Partial thyroidectomy + life long levothyroxine

ANSWER B, D


Ans b . TSH level is the first step for palpable thyroid nodule. A high or normal TSH indicates a cold nodule and this requires further evaluation with FNAC. If the TSH is low, next step would be RAIU scan.

Choice A is incorrect. Ultrasound helps to detect non palpable nodules and also, gives some useful information on whether the nodule is benign vs. malignant. However, when a thyroid nodule is palpable, TSH should be performed first and further approach should be defined based on TSH results.

Choice C is incorrect. FNAC should be subsequent step after TSH . If TSH is high or normal suggesting a cold nodule, proceed with FNAC

Choice D is incorrect because the nodule is greater than 1.5 cm and requires further evaluation as per AACE guidelines.

Choice E is incorrect. This is an appropriate option if the work-up reveals a hot nodule.



Ans. D

Papillary carcinoma of thyroid requires Total thyroidectomy and adjuvant Radio-Iodine therapy to destroy any remaining thyroid tissue. After surgery and RAIU therapy, patients are inevitably hypothyroid. Hence, they require life long levothyroxine. Life long levothyroxine is also important to keep TSH low in order to prevent recurrence of thyroid cancer. Thyroglobulin level must be carefully monitored every 6 months in patients with history of thyroid cancer to detect recurrence or persistent or metastatic disease.

Choices A, B, C, E and F are sub-optimal management and does not completely eradicate thyroid cancer.



DERM 3

A 10 y/o boy is brought by his mother for extensive rash on his lower extremities that started one day ago and has been worsening. There is no history of fever . The family just returned four days ago from a camping trip and the mother does not recall any exposure to ticks except that the boy stepped in to a bush while walking downhill. On examination, there is extensive erythema along with vesicles and bullae on the front and the back of bilateral lower extremities up until the level of the knees. The upper portion of the lower extremities is unaffected. The rest of the physical examination is normal. The best treatment for the management of this child’s condition is : •

A. Topical triamcinolone •

B. Prednisone orally •

C. Ceftriaxone intra-muscular •

D. Diphenhydramine •

E. Observation

Ans. B
Oral Prednisone



This is poison Ivy or contact dermatitis. Contact dermatitis involving more than 10% of total body surface area or associated with extensive bullae is considered severe.

Oral prednisone (Ans.b) is the treatment of choice here since the boy has greater than 10% involvement of total body surface area and also, extensive bullae.

The lesions are too extensive for Topical steroid use and can not be addressed with topical triamcinolone (Ans. A is incorrect). If the lesions are involving less than 10% body area, topical steroid is the first step.

Ceftriaxone ( Answer.C) is the treatment for Lyme Disease not for poison Ivy

Diphenhydramine may provide symptomatic relief but will not address the underlying pathology ( Answer D is incorrect)

Observation ( Answer.E) is incorrect as patient needs treatment.
ETHIC 1
You are a busy pediatrician in the city. 6 year old John has been your patient for past 3 years. John’s mother Mary brings him to your office for a recent upper respiratory infection. You treat John appropriately but he gets to be admitted to the hospital for serious pneumonia. You continue to treat John at the hospital. One evening Marissa calls you and requests that you go out for dinner with her because she is feeling so alone and has been getting quite attached to you. Which of the following is most appropriate statement?

A) You can go out with Mary because she is not your patient and you have never treated her in the past
B) You may want to avoid going out with her because she might cling to you later on
C) You should avoid relationship with her because there is potential for adverse effects on professional judgment and family member behavior concerning the patient’s health.
D) You should consult your colleague to take his advise on this issue

ans. C

It is unethical for a physician to have close or sexual relationship with both past and present patients
PEDI 1
1. A 15 year old boy presents to emergency room with severe lower abdominal pain that awoke him from sleep about 5 hours ago. The pain is sharp and radiating to the left thigh. While in the emergency room, the patient has one episode of vomiting. He denied any fever, dysuria or chills. Physical examination reveals normal vitals with blood pressure 100/60 and temperature of 98.6F. Abdominal examination is relatively benign. Scrotal examination reveals an elevated left testis that is diffusely tender to palpation. Cremasteric reflex is present on the right but absent on the left. Most important next step in managing this patient :
a. CT scan Abdomen and Pevlis
b. Testicular Ultrasound
c. Surgical Exploration
d. Intravenos Antibiotics
e. Plain X-Ray KUB
Answer is C. Surgical Exploration

The patient has testicular torsion clinical score of 3.

Key Concept : Recognize “Testicular Torsion” clinical score and determine the next step as follows :
1. Onset of pain less than six hours
2. Absence of Cremasteric reflex
3. Diffuse Testicular Tenderness.

Presence of all the three features ( score:3) is assocaited high probability of having Testicular Torsion as per a large study –> Next step, direct surgical exploration.
A score of 1 or 2 indicates moderate to low clinical probabilty –> next step, diagnostic ultrasound.
A score of 0 favors an alternative diagnosis for acute scrotum rather than Testicular Torsion.
MED 8
34 year old man with no significant past medical history is seen in your office for a painful blister that appeared on his lower lip yesterday. He compians of burning and itching in the area. He never had similar lesions in the past. He denies any fever or chills. Vital signs reveal a temperature of 98.4, HR 88, RR18 and BP of 120/76. On physical examination a lesion is seen on his lower lip as shown in the picture ( check image at http://usmlestep3blog.com/usmle-step-3-mcq/question-of-the-week-37/ ) . Rest of the physical examination is benign.

The most appropriate next step in management is:

A) Oral Acyclovir

B) Re-assurance

C) Topical Penciclovir

D) Cold compresses

E) Oral Cephalosporin
Ans. is C Topical penciclovir

Herpes Labialis:

Caused by Herpes simplex Virus Type I.
Most people are asymptomatic but only few people have recurrent outbreaks.
Triggers for outbreak are cold weather, stress, trauma.

Rx
Topical Penciclovir as your first choice.
Recurrent severe cases can be treated with oral Acyclovir.
ETHI 4
A 10 year old girl who is a Jehovah’s witness is brought to the ER after a car accident. She needs IV fluids and transfusions. The mother refuses consent for fluids and transfusions, saying its against her religious beliefs. Your next step:

A. Order the fluids and transfusions, overruling the mother.
B. Get an emergency court order
C. Get an emergency ethics consult
D. Agree with the mother and not give the treatment

Answer is A.

If you do not transfuse the kid will be DEAD


this is the reason :-

Children less than 18 yrs are minors and are legally incompetent. Parents cannot withhold life or limb saving treatments from their children.
If they refuse, use following protocol
1. Immediate emergency - treat
2. Not immediate , but still critical - refer to ethics committee or seek court intervention. The child is declared a ward of the court and court grants permission. Eg:- juvenile diabetes
3. Not life or limb threatening - listen to parents.

Child's refusal is irrelevant unless patient is an emancipated minor
If there is a clear and imminent threat to life, and a delay in treatment is likely to lead to the death of a child --> healthcare professionals can overrule parents without judicial review (eg, in this case of a blood transfusion for a Jehovah's witness child with life-threatening bleeding after a MVA).

When differences of opinion arise between health care providers and parents and if there is time to obtain judicial review --> Practitioner must first try to explain and convince the parents. If this fails, practitioners should approach courts for guidance and authority.

PHYSICIAN COMMUNICATION 1

A 17-year-old girl comes to the office for a complete physical examination before going off to college. You have been the physician for her and her brother since birth, and for both her parents for the past 20 years. The patient has been very healthy and has had all of her immunizations. Her mother is always in the waiting room as you obtain the history and perform the physical examination. The patient admits to you that she has had her first sexual experience after the prom a few weeks ago. After she tells you this she becomes very worried that you will tell her mother. At this time you should •

A. advise her to tell her mother herself so you will not have to tell her •

B. explain that you will not bring up the issue but that you cannot lie if the mother specifically asks if her daughter is sexually active •

C. perform a pelvic examination and obtain a Pap smear specimen •

D. tell the patient that your conversations with her will remain confidential •

E. try to convince her to talk about these issues with her mother

answer is D


" In establishing and maintaining a good physician-adolescent relationship, the physician should tell the patient that their conversations will remain confidential. This way, the adolescent will be able to trust the physician and will be willing to discuss issues, such as sexuality, that they do not want their parents to know about, but that may affect their health.

An exception to the confidentiality rule is the duty to warn and protect a third party from violence or infectious conditions, such as tuberculosis and syphilis "


MED 8


A 34 year old man with no significant past medical history is seen in your office for a painful blister that appeared on his lower lip yesterday. He compians of burning and itching in the area. He never had similar lesions in the past. He denies any fever or chills. Vital signs reveal a temperature of 98.4, HR 88, RR18 and BP of 120/76. On physical examination a lesion is seen on his lower lip as shown in the picture ( check image at http://usmlestep3blog.com/usmle-step-3-mcq/question-of-the-week-37/ ) . Rest of the physical examination is benign.

The most appropriate next step in management is:

A) Oral Acyclovir

B) Re-assurance

C) Topical Penciclovir

D) Cold compresses

E) Oral Cephalosporin

Ans. is C Topical penciclovir

Herpes Labialis:

Caused by Herpes simplex Virus Type I.
Most people are asymptomatic but only few people have recurrent outbreaks.
Triggers for outbreak are cold weather, stress, trauma.

Rx
Topical Penciclovir as your first choice.
Recurrent severe cases can be treated with oral Acyclovir.


Criteria for emancipated minor ( from dr.reds review)

The following are the categories of minors authorized to consent to medical care
emancipated minors (sometimes defined as those who are married, who are pregnant, who are parents, who have served in armed forces, are living apart and financially independent from their parents) :

married minors;
minors in the armed forces;
mature minors;
minors living apart from their parents ( if older than 13 yrs) ;
high school graduates;
pregnant minors
minor parents.

The idea behind this is that because these minors are no longer under effective parental supervision, parental consent is not a sensible precondition to accessing care.


SERVICES WHICH DO NOT NEED PARENTAL CONSENT :

There are some health services for which any minor can give consent. The various services for which minors are authorized to give consent in one or more states in the USA are: • emergency care; • prenatal care; • contraceptive services; • abortion; • diagnosis or treatment of venereal or sexually transmitted diseases; • diagnosis or treatment of reportable, infectious, contagious or communicable diseases; • HIV/AIDS testing or treatment; • counseling or treatment for drug- or alcohol-related problems; • collection of medical evidence or treatment for sexual assault; and • in- or outpatient mental health services.


NOTE : If a patient who is a minor requests termination of pregnancy, advice on contraception, or treatment of sexually transmitted diseases without a parent's knowledge or permission, the physician may wish to attempt to persuade the patient of the benefits of having parents involved, but should be aware that a conflict may exist between the legal duty to maintain confidentiality and the obligation toward parents or Information should not be disclosed to others without the patient'sguardians permission . In such cases, the physician should be guided by the minor's best interest in light of the physician's conscience and responsibilities under the law.

An 18-year-old female gymnast lands her dismount
from the balance beam awkwardly. She reports the
knee buckling, hearing a pop and experiencing immediate
right knee pain. She presents to your office
45 minutes after the injury. She is able to bear some
weight on the leg but reports it is already swollen and
feels loose. On exam there is a knee effusion present.
The MOST likely isolated injury experienced by
this athlete is:
A) Medial meniscus tear.
B) Medial collateral ligament (MCL) sprain.
C) Distal quadriceps/patellar tendon rupture.
D) Anterior cruciate ligament (ACL) rupture.
E) None of the above.

The best test to confirm the diagnosis of the
above injury would be:
A) Plain film radiographs.
B) McMurray test.
C) Lachman test.
D) Anterior drawer test.
E) None of the above can confirm this diagnosis
independently.

Discussion
The correct answer is D. Did the patient or someone
else hear a pop? If yes, suspect ACL tear (80%), meniscal
injury (15%), and rarely a fracture. When did you
notice swelling? If 0–12 hours after the injury, suspect
ACL tear or patellar dislocation/subluxation; if 12–24
hours, suspect meniscal injury. If there is hemarthrosis
on aspiration, suspect ACL injury (GREATER THAN 75%), patellar subluxation,
or intraarticular fracture. A history of “My
knee gives way; buckles; feels loose; or comes apart”
may be secondary to patellar subluxation/dislocation,
ACL deficiency, or arthritis. Collateral ligament injuries,
MCL, or lateral collateral ligament (LCL) do not typically
present with significant effusion and typically feel
stable with forward ambulation but are painful with sideto-
side movements. Muscle or tendon rupture may
cause buckling, but will not typically cause effusion and
will generally have an obvious deformity and inability to
bear weight.

Discussion
The correct answer is C. In the hands of an experienced
clinician, the Lachman test is the most sensitive
test for ACL insufficiency (80%–95%). The anterior
drawer sign is negative in about 50% of acute ACL
tears, and often is negative subacutely. McMurray test is
used to evaluate for a meniscal tear. Plain films should
be obtained for all patients with acute knee injury with
effusion or suspected ACL tear. However, x-rays are
rarely positive for more than effusion or Segond fracture
(avulsion of the lateral joint capsule from the tibia).
Although an MRI may be considered a gold standard
test, its sensitivity has been reported as 97% when compared
with arthroscopy findings, and is positive in only
82% in cases of complete rupture. An orthopedic consult
is generally indicated if ACL injury is suspected,
and obtaining one is less expensive than MRI.
TN:
1] age 60-70, Strictly unilateral, affects the right side of the face 5 times more frequently than the left.
2] stabbing unilateral facial pain that is triggered by chewing or similar activities or by touching affected areas on the face.
3] Chewing, talking, smiling, or drinking cold or hot fluids may initiate TN pain. Touching, shaving, brushing teeth, blowing the nose, or encountering cold air from an open automobile window also may elicit pain.
4] Most of times Hypersensible....and in trigeminal region only..
In addition to holding Metformin, which of the following interventions would be most likely to reduce a patients risk of developing contrast induced nephropathy? ( pt is diabetic ofcourse)

A. N- Acetylcysteine (NAC) and IV saline
B. NAC and Mannitol
C. Sod. bicabonate and IV Saline
D. Sod. bi carbonate and Mannitol
E. Mannitol and IV Saline

C.

Radio-Contrast ATN from Dr.Red lectures

Risk factors: CRF especially diabetic, CHF, elderly and multiple myeloma
ATN begins abruptly and SCr peaks in 3-5 days
Usually reversible, but some have prolonged renal damage
Usually nonoliguric, but oliguria can be seen and FE Na decreased.

Prevention :
Consider non contrast study if high risk
D/C NSAID’s, ACE inhibitors. ARB’s etc
Ensure optimal volume status and RBF - 0.9% saline @ 1cc/kg/hr for 6 hours prior or
D5W + 3 amps NaHCO3 @ 3.5 cc/kg/hr for 1 hour and then 1 cc/kg/hour for 6 hours after

N-acetylcysteine 600mg bid pre and day of study ( controversial)
Minimize amount of contrast and consider iso-osmolar agent - nonionic and/or isosmolar contrast are less nephrotoxic.
No role for Mannitol or other diuretics in prevention

A 36-year-old male diabetic presents with a 3-day history
of irritation, itching, dysuria, and redness at the
tip of his penis. He is monogamous with his wife, and
he denies any history of high-risk sexual behavior or
STIs. On exam, you find an afebrile patient in no acute
distress. The penis is circumcised, and the glans penis
is red, tender, and edematous. There are numerous
small, white papules on the glans

Which of the following is the most appropriate
treatment?
A) Sitz baths and improved hygiene.
B) Oral doxycycline.
C) Topical bacitracin.
D) Topical miconazole.
E) Topical steroids.
Discussion
The correct answer is D. This patient has balanitis,
defined as an inflammatory condition of the glans penis
(balanoposthitis is inflammation of the glans and foreskin).
Some authors believe that balanitis is a noninfectious,
inflammatory condition. Others implicate
infectious causes. Of infectious causes, the most common
is Candida albicans, especially in diabetics. This
patient has classic findings of candidal balanitis and he
is diabetic. Therefore, the most appropriate therapy is
a topical antifungal agent, such as miconazole. Topical
and oral antibiotics will not help, and topical steroids
should be avoided. Sitz baths and improved hygiene
should be encouraged, but they should not be
employed without an antifungal agent.

MED 44

A 44 year old man presents to your office with pain and swelling of the small joints in his hands and wrists. The symptoms have been progressing over the past 4 months. He denies any fever or weightloss. He reports stiffness in his both hands that occurs every morning and lasts for 2 hours. On examination, he has symmetrical involvement of both wrists and proximal interphalangeal joints. The involved joints are swollen and tender. Laboratory tests shows high ESR, negative rheumatoid factor, and a positive anti-CCP antibody. The most appropriate next step in management :

A. Start etanercept
B. Start Ibuprofen and follow-up in one month.
C. Start Ibuprofen and Methotrexate
D. Obtain plain x-rays of hands and wrists
E. Obtain anti-nuclear antibodies




Ans. C
This patient has severe rheumatoid arthritis. He has all the criteria for the diagnosis of RA ( morning stiffness greater than 1hr, symmetricity, hand joint involvement, more than 3 joints, +ve CCP and bony erosions). His disease can be classified as "severe" because he has high ESR, high CCP and most importantly, he has erosive bony disease.

Therapy depends on severity at the time of diagnosis ( in early RA) :-
Mild RA : NSAID alone can be started first. NSAID does not prevent disease progression or erosive bone disease. If symptoms persist or progress while on NSAIDS or if no remission occurs after six weeks on NSAID therapy, a disease modifying agent must be added ( DMARD). For mild disease, a less toxic DMARD such as Hydroxychloroquine or Sulfasalazine must be used initially ( not methotrexate).

Moderate RA : NSAID + less toxic DMARD such as hydroxychloroquine should be started from the time of diagnosis.

Severe RA : An NSAID along with a more potent DMARD such as Methotrexate should be started together as initial therapy. NSAID alone should not be used as sole therapy in severe RA as it will not prevent disease progression. In patients who can not be started on MTX ( for contraindications), a TNF alpha inhibitor such as leflunomide or etanercept must be started as initial DMARD.

Ans. A is incorrect. Prednisone is usually used for treating RA flares.

Ans. B is incorrect. This option is appropriate if the patient is determined to have early, mild RA. Patients can be started on NSAID alone and follow up in 1 month to see if there is remision. If disease is still present, DMARD must be added.

Ans. D is incorrect. This option is correct if the patient is determined to have early, severe RA and if the patient can not be started on DMARD such as methotrexate

Ans. E is incorrect. This option is appropriate if the patient is determined to have early, mild RA or moderate RA. Patients can be started on NSAID alone in mild RA and follow up in 1 month to see if there is remision. If THE disease is still present, a mildly toxic DMARD must be added
such as hydroxychloroquine or sulfasalazine.
-----------------

MED 46
A 69 year old woman presents to your clinic with history of pain in bilateral hands. Her symptoms started about 3 years ago but lately, have been more significant. She denies any morning stiffness or redness or swelling of the joints. On examination, there are hard growths at distal interphalangeal joints. Clinically, you make a diagnosis of Osteoarthritis. Radiographically, which of the following features is LEAST likely to be seen in Osteoarthritis :

A. Narrowing of the joint spaces in involved joints
B. Sclerosis near the articular surface
C. Bony erosions
D. Osteophytes
E. Sub-chondral cysts

MED 43

A 49 yo woman with past medical history history of rheumatoid arthritis presents to the emergency room with a 2 day history of a severely painful, warm, swollen Right knee. The patient has been on treatment with prednisone and methotrexate . Her symptoms were well controlled until recently. She denies any pain or swelling in any other joints at this time. Physical examination reveals swollen and tender right knee. She is afebrile. The most appropriate next step in management is:

A. Add infliximab
B. Increase dose of Methotrexate
C. Obtain x-ray of the Knee
D. Arthrocentesis
E. Intra-articular glucocorticoid injection

D IS THE ANSWER


MED 45

A 22 year old man with history of chronic backache presents to your office. The patient has a history of progressive low back pain for 3 years. He relates his pain to a motor vehicle accident that happened to him 3 years ago. X-rays of the spine were performed three years ago at the start of his symptoms and were normal. He reports that his pain is worst in the morning but gradually improves towards the end of the day. The patient has been using over the counter ibuprofen and tylenol with out any relief. He was recently started by his primary care doctor on oxycodone which he takes 6 times daily as needed for pain. This did not relieve his pain either. The patient is here to see you for a second opinion. The most appropriate next step in management is :

A. Plain X-ray of lumbar spine and pelvis
B. MRI of the lumbar spine
C. Prescribe long acting narcotic
D. Physical Therapy
E. HLAB27 testing

A. Plain X-ray of lumbar spine and pelvis



MED 47

Q64) A 44 year old man presents to your office with pain and swelling of the small joints in his hands and wrists. The symptoms have been progressing over the past 4 months. He denies any fever or weightloss. He reports stiffness in his both hands that occurs every morning and lasts for 2 hours. On examination, he has symmetrical involvement of both wrists and proximal interphalangeal joints. The involved joints are swollen and tender. Laboratory tests shows high ESR, negative rheumatoid factor, and a positive anti-CCP antibody. X-ray of the wrist and hands reveal erosions in the proximal phalanges and ulnar styloid process. The most appropriate next step in management :

A. Prednisone
B. Start NSAID and follow-up in one month.
C. Start NSAID and Methotrexate
D. Start Infliximab
E. Start NSAID and Hydroxychloroquine


Ans. C
This patient has severe rheumatoid arthritis. He has all the criteria for the diagnosis of RA ( morning stiffness greater than 1hr, symmetricity, hand joint involvement, more than 3 joints, +ve CCP and bony erosions). His disease can be classified as "severe" because he has high ESR, high CCP and most importantly, he has erosive bony disease.

Therapy depends on severity at the time of diagnosis ( in early RA) :-
Mild RA : NSAID alone can be started first. NSAID does not prevent disease progression or erosive bone disease. If symptoms persist or progress while on NSAIDS or if no remission occurs after six weeks on NSAID therapy, a disease modifying agent must be added ( DMARD). For mild disease, a less toxic DMARD such as Hydroxychloroquine or Sulfasalazine must be used initially ( not methotrexate).

Moderate RA : NSAID + less toxic DMARD such as hydroxychloroquine should be started from the time of diagnosis.

Severe RA : An NSAID along with a more potent DMARD such as Methotrexate should be started together as initial therapy. NSAID alone should not be used as sole therapy in severe RA as it will not prevent disease progression. In patients who can not be started on MTX ( for contraindications), a TNF alpha inhibitor such as leflunomide or etanercept must be started as initial DMARD.

Ans. A is incorrect. Prednisone is usually used for treating RA flares.

Ans. B is incorrect. This option is appropriate if the patient is determined to have early, mild RA. Patients can be started on NSAID alone and follow up in 1 month to see if there is remision. If disease is still present, DMARD must be added.

Ans. D is incorrect. This option is correct if the patient is determined to have early, severe RA and if the patient can not be started on DMARD such as methotrexate

Ans. E is incorrect. This option is appropriate if the patient is determined to have early, mild RA or moderate RA. Patients can be started on NSAID alone in mild RA and follow up in 1 month to see if there is remision. If THE disease is still present, a mildly toxic DMARD must be added
such as hydroxychloroquine or sulfasalazine.



MED 41

A 24 year old woman presents to the Emergency Room with complaints of left sided weakness and slurred speech. The patient has history of Systemic Lupus Erythematosus. Her SLE was diagnosed 2 years ago when she had malar rash and abnormal blood counts. She reports that she has not received any treatment for it since her physician felt this was not needed at that time. She denies any history of kidney involvement. She denies any joint pains or rash. Physical examination revealed left hemiparesis consistent with cerebrovascular accident. A CT of the head reveals right parietal infarct with out any bleed. An EKG is obtained and is normal. Anti-cardiolipin antibody is +ve which was also positive 1 year ago as per her old records . The patient is started on adequate therapy and follows up in your office 1 month later. Which of the following interventions is most appropriate to prevent recurrent stroke in her case?
a) Aspirin for life
b) Warfarin for 1 year
c) Warfarin for 6 months
d) Warfarin for life
e) Hydroxychloroquine


warfarin for life is correct answer.



MED 32,33


A 17 year old boy is seen in your office for a recurrent rash on his back. He noticed that the rash became more obvious in summer as it shows up more prominently in his tanned skin. He is concerned about his appearance and has stopped going to the beach in summer. He denies any itching or pain. He is sexually active and occassionally uses condoms. He denies alcohol or drug use. Physical examination reveals macular rash on his back as shown below. http://usmlegalaxy.files.wordpress.com/2010/08/picture1.jpg

The Most likely diagnosis:
A) Secondary Syphilis
B) Vitiligo
C) Pityriasis Rosea
D) Tinea Versicolor
E) Tinea Capitis

Q41) The most appropriate treatment for this patient’s condition:
A) Oral Prednisone
B) Topical Selenium Sulfide
C) Oral Flucnozole
D) Reassurance and observation
E) Topical Corticosteroid
F) Benzathine Penicillin Intramuscular


ANSWER IS D, B
MED 39,40

Q58) A 30 year old man comes to your office with complaints of pain in both the wrists and in the hands for the past two months. The pain is particularly worse in the nights and awakens him from sleep. It radiates to the forearms from the wrists. Occassionally, the pain is associated with abnormal sensations in both hands. He denies any pain or paresthesiae at this time. Upon further questioning, he also reports some mild stiffness & very mild pain in the neck in the past two weeks. Physical Examination is normal. The most appropriate initial investigation is:
A. Nerve conduction studies
B. Plain X-ray of the wrist
C. Plain X-ray of the cervical spine
D. Rheumatoid factor
E. MRI cervical spine

Q59) The most likely underlying etiology of this patient’s clinical features is :
A. Spinal cord compression
B. Brachial plexopathy
C. Rheumatoid arthritis
D. Hypothyroidism
E. Cervical Spondylosis


Q58) Ans. A

The patients clinical features are diagnostic of carpal tunnel syndrome. Carpal tunnel syndrome can be bilateral in up to 60% of cases. This occurs due to compression of the median nerve in the carpal tunnel. It is characterized by dull pain which is typically worse in the nights ( important clue). Pain is often accompanied by paresthesiae and motor weakness in the hand. In some patients, pain may radiate in to forearms from the wrists. This history of direction of radiation of pain is important and can be helpful in excluding other causes such as brachial neuralgia. In carpal tunnel, pain radiates upwards from wrist in to the forearm. In brachial neuralgia, pain radiates down the shoulder in to the arm. Nerve conduction studies (NCS) and electromyography (EMG) are helpful in establishing the diagnosis and to rule out other causes of similar pain. Provocative maneuvers such as Phalen test and Tinel's sign are only moderately sensitive for the diagnosis of Carpal Tunnel Syndrome (CTS).

Ans. B is incorrect. Plain x-rays are not helpful in confirming the diagnosis of CTS.

Ans. C is incorrect. This patient's clinical features are consistent with the diagnosis of CTS. Plain X-ray cervical spine is not helpful in the diagnosis of CTS. It is important to note that the patient's pain in the hands has been present for more than 2 months where as neck pain and stiffness is much more recent. Physical examination of spine is also normal ruling out any acute pathology in the spine. The mild stiffness in his neck likely points to underlying association such as Rheumatoid arthritis ( RA) . CTS can be associated with RA.

Ans. D is incorrect. Though this patient may have underlying Rheumatoid arthritis, testing for RF is not useful in confirming the diagnosis of CTS.

Ans. E is incorrect. MRI of cervical spine is useful in diagnosing acute cervical spine conditions such as trauma or disc herniation. It is also sensitive to detect the lesions in Brachial plexopathy. This patient does not have brachial plexopathy. The pain in brachial plexopathy radiates down the shoulder in to the upper arm . It may be associated with numbness and motor weakness.


Q59) Ans. C.
The patient's clinical features are consistent with CTS. The only condition among the choices that fits in to this clinical scenario is Rheumatoid Arthritis (RA). CTS is the most common neurologic manifestation of rheumatoid arthritis. This may occur due to RA related finger-flexor tenosynovitis within the carpal tunnel. Mild stiffness and pain in his neck area may suggest early atlanto axial involvement in RA.

Ans. A is incorrect. Spinal cord compression (SCC) at cervical level is more acute and dramatic and will be associated spastic quadriparesis. The patient's chronicity of symptoms exclude the diagnosis of SCC.

Ans. B is incorrect. This patient has CTS. He does not have brachial plexopathy. The pain in brachial plexopathy radiates down the shoulder in to the upper arm . It may be associated with numbness and motor weakness.

Ans. D is incorrect. Hypothyroidism is one of the conditions associated with CTS. This patient does not have features to suggest Hypothyroidism.


Ans. E is incorrect. Cervical spondylosis is a degenerative disease of cervical spine which eventually, causes cervical canal stenosis. It may present with cervical radiculopathy where the pain radiates down the shoulder in to the arms. Paresthesiae in the involved nerve roots can occur. There is no increase in pain during the nights in cervical radiculopathy unlike the pain in CTS ( Sleep is a provocative factor for pain in the CTS)



MED 42

A middle aged man presents with a history of foot pain on walking for a few weeks. The patient has a history of long standing diabetes mellitus for more than 15 years. He has been on Metformin and Glyburide combination. His HGBA1C that was obtained 3 months ago revealed inadequate control at 9%. He reports pain and swelling in his right foot for about one month. On examination the foot is swollen & tender to touch. Neurlogical examination reveals loss of vibratory sensation and position sensation in bilateral feet. There is also impaired light touch until the level of knees bilaterally. Joint motion at the level of ankle is within normal limits. Complete blood count , creatinine and ESR are with in normal limits. Most likely working diagnosis for his right foot pain is :
a) Chronic Gout
b) Septic arthritis
c) Peripheral Neuropathy
d) Charcot arthropathy
e) Reflex Sympathetic Dystrophy


Ans. D

The physical examination findings and clinical history in this patient are suggestive of Charcot Arthropathy. Charcot arthropathy is a condition that affects the joints and the bones in patients with neuropathy ( also, referred to as Neuropathic arthropathy). Diabetes is the most common cause of neuropathic arthropathy in the USA. Clinical features may be acute or chronic. Acute charcot arthropathy may follow a minor traumatic event and presents with sudden onset of warmth, erythema, swelling and pain over the affected foot or ankle. Pain is relatively much lesser when compared to the extent of physical findings. Repeated acute events of charcot's may progress to persistent artrhropathy characterized by insiduous swelling over several months and loss of the arches of the foot. Physician must be aware of this condition that can occur on the background of peripheral neuropathy in a diabetic patient. Important differential diagnosis Septic arthritis, gout and rheumatoid arthritis must be considered and excluded.

Ans. A is incorrect. Acute gout is less likely in view of the chronicity of symptoms lasting more than few weeks, absence of joint effusion and relatively, less intense pain when compared to physical exam findings.

Ans. B is incorrect. The chronicity of symptoms lasting more than few weeks, absence of joint effusion and preserved range of motion at the joints make the possibility of septic arthritis less likely. If joint effusion is present, arthrocentesis must always be performed to rule out septic arthritis even in the presence of high clinical suspicion of Charcot arthropathy.

Ans.C is incorrect. The patient does have peripheral neuropathy. But her neuropathy does not explain the foot swelling and pain.

Ans. E is incorrect. Reflex sympathetic dystrophy (RSD) is characterized by vasomotor instability, severe burning pain in hands or feet, swelling and trophic changes. Symptoms in early stage may mimic those of peripheral neuropathy. Often, there is history of antecedent trauma. This patient has no history of antecedent trauma and her pain is much less intense when compared to the pain in RSD.





MED 37 ,38
56) A 42 year old presents with a pain & swelling in the left knee. The symptoms started 3days ago and have been progressively worsening. Upon further questioning, the patient tells you that he has experienced intermittent pain and swelling in the toes, wrists and ankles for more than 10 years. On examination the left knee is swollen and warm to touch. There is also soft tissue swelling of the wrists, ankles and right foot. He has a 10 year history of intermittent pain & swelling in the toes, wrists & ankles. On examination the right knee is warm to touch with an effusion, & there is soft tissue swelling of the wrists, right ankle & right foot. X-ray of the wrist is shown below. Laboratory studies reveal increased ESR at 90mm/hr WBC are elevated at 12k.
see picture : http://usmlegalaxy.files.wordpress.com/2010/09/xray-wrist.jpg
The most likely diagnosis :
A. Early erosive osteoarthritis

B. Reactive Arthritis

C. Psoriatic Arthritis

D. Pseudo-Gout

E. Rheumatoid Arthritis

Q57) The most important next step in management :

A) Obtain Rheumatoid Factor level

B) Obtain Anti citrullin peptide level

C) Start prednisone

D) Start ibuprofen and Methotrexate

E) Arthrocentesis of the Right knee

Q56) Ans. E

The patient's clinical presentation is consistent with acute flare of Rheumatoid arthritis. The x-ray reveals extra-articular erosion of ulnar styloid process. The involvement of proximal joints with accompanying soft tissue swelling, symmetrical involvement, history of chronic arthritis and extra-articular erosions on the x-ray are consistent with the diagnosis of Rheumatoid Arthritis. American Rheumatism Association (ARA) has developed 6 criteria for the diagnosis of RA. 4 out of this 6 criteria are necessary to diagnose RA. These include morning stiffness more than one hour, arthritis of 3 or more joint areas, arthritis of hand joints (wrist, MCP or PIP joint), Symmetric arthritis, Rheumatoid nodules, Serum rheumatoid factor
and Radiographic changes typical of rheumatoid arthritis on posteroanterior hand or wrist radiographs, which must include erosions within the involved joint or adjacent to the involved joints. This patient already has 4 out of six criteria for RA.

Ans. A is incorrect. Early onset erosive OA is an important differential diagnosis of RA but the patient's radiographic features, symmetricity, proximal joint involvement are more typical of RA.

Ans. B is incorrect. Reiter's syndrome is characterized by asymmetric pattern of joint involvement, symptoms or signs of enthesopathy ( inflammation at the site of tendon insertion) and radiographic evidence of sacro-ileitis. This patient has symmetrical arthritis which readily eliminates the possibility of Reiter's syndrome.

Ans. C is incorrect. Psoriatic arthritis can be either symmetric or asymmetric oligoarthritis or polyarthritis. Symmetric polyarthritis presentation of psoriatic arthritis is sometimes difficult to differentiate from RA. In addition to inflammatory arthritis, the diagnosis of psoriatic arthritis requires three of the following features : dactylitis, psoriatic skin lesions, typical nail lesions ( pitting or onycholysis), negative rheumatoid factor and juxta-articular new bone formation seen on the x-rays. In the presence of typical psoriatic skin lesions, only one additional feature of the above is sufficient for diagnosis. The patient in the question does not meet this criteria.

Ans. D is incorrect. Pseud-gout is usually acute mono-arthritis or oligoarthritis. It is very uncommon for pseudo-gout to present with polyarthritis. Pseudo-gout is also characterized by chondro-calcinosis which is deposition of calcium pyrophosphate crystals in the articular cartilage. Chondro-calcinosis can be visualized on the X-rays. The x-ray presented in the above case does not reveal chondrocalcinosis.

Q57) Ans. E
The patient has clinical criteria sufficient to diagnose Rheumatoid Arthritis. The current presentation of acute left knee swelling and pain could be related to a flare of RA. However, septic arthritis should be included in the differential diagnosis of any acute large joint swelling. Septic arthritis is also more common in RA patients when compared to general population. Hence, a joint aspiration must be performed to exclude septic arthritis before attributing such an acute large joint presentation to a RA flare.

Ans. A is incorrect. The patient satisfies clinical criteria for RA diagnosis. A rheumatoid factor is adjunctive and will not help in confirming the etiology of her left knee swelling.

Ans. B is incorrect. The patient satisfies clinical criteria for RA diagnosis. A anti-citrullinated peptide is adjunctive and will not help in confirming the etiology of her left knee swelling. Anti-CCP positivity also carries an unfavorable prognosis in RA.

Ans. C is incorrect. It is inappropriate to start steroid with out excluding septic arthritis.

Ans. D is incorrect. It is inappropriate to start treatment of RA with out excluding septic arthritis in this patient's left knee. Treatment for RA can be initiated after arthrocentesis. Ibuprofen can be used to relieve her symptoms and a DMARD such as Methotrexate should be started due to presence of erosions on the radiographs. In the absence of erosions, a milder DMARD such as hydroxychloroquine should be started.


MED 31



A 55-year-old man presented for a regular follow-up to your office 6 months ago ago at which time a palpable nodule of 1.7 cm was noted in the left thyroid lobe. A TSH level was normal. Subsequently, he underwent an FNAC which revealed Papillary Carcinoma of thyroid. Staging work-up revealed no evidence of distant metastases and a neck CT scan did not reveal any lymphadenopathy. He underwent total thyroidectomy combined with RAIU therapy and was started on levothyroxine. The patient arrives for follow up visit at 6 months. His TSH level at 6 month is less than 0.1. He denies any symptoms such as palpitations or chest pain or heat intolerance. His weight is unchanged. Most appropriate next step in management?

a) Reduce levothyroxine dose
b) Discontinue levothyroxine
c) Obtain serum thyroglobulin level
d) Obtain anti-thyroglobulin antibodies and serum thyroglobulin levels.
e) Radio-iodine scan

Ans. D

Both thyroglobulin and thryroglobulin antibodies must be obtained. Serum thyroglobulin level must be monitored every 6 months to detect persistent or recurrent disease after the surgery. About 25% of patients tend to have antithyroglobulin antibodies even after complete surgical removal of thyroid gland. These antibodies can interfere with serum thyroglobulin assay and can lead to falsely low serum thyroglobulin level. Hence, the antibodies must be measured along with serum thyroglobulin for accurate interpretation of the assay.

Ans. A is incorrect. Suppressive doses of levothyroxine must be used so as to keep TSH low thyroid cancer patients. This reduces recurrence.

Ans. B is incorrect. Suppressive doses of levothyroxine must be used so that TSH can be kept low in thyroid cancer patients.

Ans. C is incorrect since both antibody as well as thyroglobulin must be measured to rule out the possibility of falsely low serum thyroglobulin level.

Ans. E is incorrect. RAIU scan must be used to detect the thyroid tissue only if serum thyroglobulin levels are detectable. This will be subsequent step if serum Tg level is elevated.

MED 36

1. A 4-month-old girl is brought by her concerned mother because the child has been inconsolably crying for 6 hours. The child is breast fed and has been doing well. There is no vomiting, diarrhea, constipation, or increased gas. The mother has not changed her diet and the infant is on no medications. There has been no fever. On physical examination the child is active and screaming. There is no fever. The physical examination is normal except that there is redness and swelling affecting the left third toe with indentation proximal to the redness. It is tender to touch. There was no history of similar problems. The picture is shown below:
http://usmlegalaxy.files.wordpress.com/2010/09/swollen-infant-toe.jpg


The most likely working diagnosis:

A. Trauma

B. Herpetic whitlow

C. Hairy tourniquet syndrome

D. Acute paronychia

E. Ingrown toe nail

F. Acute Gout



2. The most appropriate next step in management :

A. Joint aspiration

B. X-ray of the foot

C. Inspect the toe for hair strangulation

D. Incision and drainage

E. Topical acyclovir


MED 30

A 75 y/o woman with past medical history of CVA, HTN, DM type II is sent to the Emergency Room from Nursing home for evaluation of fever and altered mental status. Vitals reveal a temperature of 101F, BP 100/60, RR 22, HR 110. Physical examination reveals an elderly woman not responding to verbal stimuli but moans in response to deep pain. Echymoses are seen on lower extremities. A foley catheter is present draining cloudy urine. Lab studies show Hgb of 8.6, WBC 12K, Platelets 15k, BUN 48 and Creatinine 3.2. Prothrombin time is 14.8 and Partial thromboplastin time is 58. LDH level is elevated at 600. A peripheral blood smear is shown. Which of the following features would most likely help in identifying the etiology of this patient's thrombocytopenia?

p.s : i am not able to post picture here but the smear is showing fragmented red cells

A. Fragmented Red Blood Cells ( Schistocytes)
B. Decreased Fibrinogen and Increased D-dimer
C. Elevated LDH
D. Decreased Reticulocyte Count


Ans. B

The patient presents with fever and possible sepsis. Cloudy urine indicates that UTI is the possible source of sepsis. Recognize that severe sepsis can lead to multi-organ dysfunction such as hypotension, encephalopathy. Disseminated intravascular coagulation and renal insufficiency. The latter three are seen in this patient.

Recognize that the important difference between DIC and TTP is that DIC is a consumption coagulopathy i.e; it consumes the entire coagulation factors along with platelets. Hence, PT and PTT are elevated and fibrinogen is decreased in DIC but not in TTP. The intravascular thrombi in DIC are fibrin thrombi - the lysis of these lead to increased D-Dimer and Fibrin Split products. TTP is a consumption thrombocytopenia and is composed of platelet thrombi not fibrin - so, D-dimer is usually normal in TTP and HUS.


The distractors in the question are typical TTP like pentad and scistocytes on the smear. However, realize that severe sepsis can have all these features ( Fever, thrombocytopenia, DIC leading to MAHA, altered mental status and renal failure). So, the entire clinical scenario should be put together in arriving at the diagnosis.

The peripheral blood smear shows Schistocytes.
Recognize that schistocytes are not specific for TTP. Schistocytes can occur in any condition that is associated with Microangiopathic Hemolysis (MAHA). MAHA can occur in conditions where intravascular thrombi rub against RBC in tiny capillaries leading to RBC fragmentation and hemolysis eg: MAHA can be seen in TTP, HUS, DIC, HELLP Syndrome and Malignant Hypertension.


Ans. A is incorrect. Presence of Schistocytes indicate MAHA from any cause and hence, not specific for DIC. MAHA can be seen in the following : Malignant hypertension, HEELP syndrome, TTP, HUS, DIC and Prosthetic valve malfunction ( macro type hemolysis)

Ans. C is incorrect. Increased LDH can be seen in hemolysis from any cause and is not specific to DIC.

Ans. D is incorrect. Hemolytic anemia is associated with increased reticulocyte count not decreased retic.



KEY CONCEPTS:


1. DIC is a consumptive coagulopathy-thrombocytopenia and occurs secondary to several causes.
2. TTP is non-immune consumptive thrombocytopenia. PT and PTT are usually normal.
3. Severe sepsis can resemble TTP. Full clinical picture should be considered in decision making. Source of sepsis should be sought and ruled out in suspected cases before making a diagnosis of TTP
4. MAHA is not specific for TTP. Recognize other causes of MAHA are DIC, HUS, HELLP and Malignant Hypertension.




MED 34,35
A 45-year-old woman is very concerned about an eruption on her face. She has developed lesions on the cheeks and forehead over the last few months. They are not associated with itching. The eruptions are worsened with by prologed exposure to sun, excessive stress and hot drinks. She denies any history of alcoholism. Physical examination reveals a papular eruptions with assocaited erythema, telangiectasia and pustules. There are no lesions in any other areas except on her face.
PICTURE AT
http://usmlegalaxy.files.wordpress.com/2010/08/picture2.jpg

the Most Likely Diagnosis :
A.Nodulo cystic acne
B. Rosacea
C.Porphyria Cutanea Tarda
D. Seborrheic Dermatitis
E. Cutaneous Lupus

The most apprpriate next step in management :
A) Topical Corticosteroid
B) Topical Benzoyl Peroxide
C) Oral Isotretinoin
D) Topical Metronidazole
E) Oral Doxycycline

b-DX Rosacea.
d


MED 28

A 55 y/o woman with history of well controlled DM Type II presents for her regular follow-up visit. She has no new complaints. She has been well controlled on Metformin alone with a hemoglobin A1c of 6.5. The patient is afebrile with a B.P 96/72, HR 88, RR 16. Physical examination is benign except for decreased sensation in her bilateral lower extremities consistent with diabetic neuropathy and bilater lower extremity edema. Her last urinary microalbumin about one year ago was negative. A repeat dipstick test now is positive for protein and blood but negative for leucoesterase and nitrite. Subsequent urine microscopy reveals 4 dysmorphic RBCs/HPF and red cell casts. Labs reveal elevated serum creatinine at 1.4 as opposed to her baseline creatinine of 0.8 6 months ago. The next important step in approaching this patient’s Renal Insufficiency is:

A) Obtain CPK level
B) 24 hour urine for microalbumin
C) Start ACE inhibitor
D) Repeat urinalysis in 3 months
E) Referral to Nephrologist and Renal biopsy
F) Start emperic antibiotic therapy for UTI





Ans. E.

The presence of red cell casts indicate glomerular origin of this patient’s hematuria. Etiologies include various glomerulonephritis and hence, a renal biopsy is warranted. A nephrotic syndrome that is expected with Diabetic nephropathy should not have dysmorphic red cells or red cell casts in urine. Presence of these indicates Nephritis but not nephrotic syndrome.

A. is not the answer because here a positive dipstick is also followed by a positive urinalysis indicating true hematuria. A myoglobinuria will have positive dipstick but no RBCs on urine microscopy.

B. is not the answer because it does not add anything to elucidate the cause of this patient’s hematuria. In view of concomitant presence of RBC casts, this patient’s acute onset protein in the urine may be secondary to glomerulonephritis rather than DM nephropathy.

C. Presence of RBC casts indicate glomerual cause of hematuria. So, the patient should be referred to a nephrologist rather than a urologist

D. Repeating urinalysis in 3 months is appropriate for a new microscopic hematuria with out any features suggesting kidney involvement. Here hematuria is clearly glomerular in origin and requires further work up as soon as possible.

F. Is incorrect because this patient has no evidence of UTI. The patient’s clinical features as well as urinalysis findings do not suggest a UTI. The patient has no fever or dysuria. Dipstick is negative for leucoesterase or nitrite. Urinalysis has no WBCs or WBC casts. Absence of all these make UTI an unlikely etiology of her hematuria.
MED 14,15

46. A 55-year-old man presented for a regular follow-up to your office 2 weeks ago at which time a palpable nodule of 1.7 cm was noted in the left thyroid lobe. He denies a history of head and neck irradiation, hoarseness, pain, dysphagia, or hemoptysis. His physical exam is otherwise normal, with no lab abnormalities. Most appropriate next step in management?

A. Ultrasound of thyroid

B. TSH level

C. Fine Needle Aspiration ( FNAC)

D. Observation

E. Suppressive therapy with levothyroxine

47. The patient in Q1. subsequently, underwent an FNAC which revealed Papillary Carcinoma of thyroid. Staging work-up revealed no evidence of distant metastases and a neck CT scan does not reveal any lymphadenopathy. The most appropriate management of his thyroid cancer involves:

A. Radio iodine therapy ( RAI)

B. Partial thyroidectomy

C. Total thyroidectomy

D. Life long levothyroxine + Total Thyroidectomy + RAI therapy

E. Total Thyroidectomy + Life long levothyroxine

46. Ans b . TSH level is the first step for palpable thyroid nodule. A high or normal TSH indicates a cold nodule and this requires further evaluation with FNAC. If the TSH is low, next step would be RAIU scan.

Choice A is incorrect. Ultrasound helps to detect non palpable nodules and also, gives some useful information on whether the nodule is benign vs. malignant. However, when a thyroid nodule is palpable, TSH should be performed first and further approach should be defined based on TSH results.

Choice C is incorrect. FNAC should be subsequent step after TSH . If TSH is high or normal suggesting a cold nodule, proceed with FNAC

Choice D is incorrect because the nodule is greater than 1.5 cm and requires further evaluation as per AACE guidelines.

Choice E is incorrect. This is an appropriate option if the work-up reveals a hot nodule.



47. Ans. D

Papillary carcinoma of thyroid requires Total thyroidectomy and adjuvant Radio-Iodine therapy to destroy any remaining thyroid tissue. After surgery and RAIU therapy, patients are inevitably hypothyroid. Hence, they require life long levothyroxine. Life long levothyroxine is also important to keep TSH low in order to prevent recurrence of thyroid cancer. Thyroglobulin level must be carefully monitored every 6 months in patients with history of thyroid cancer to detect recurrence or persistent or metastatic disease.

Choices A, B, C, E and F are sub-optimal management and does not completely eradicate thyroid cancer.


If thyroid nodule palpable –> Get TSH First.
a) If High TSH – suggests cold nodule/ Hashimatos –> Get FNAC (source: NEJM)( AACE recommends ultrasound as the next step here because hashimatos may have benign nodularity that regress with therapy and ultrasound will help to see if there are suspicious features. If U/S suspicious, then FNAC is recommended. This may be optimal approach because hurthle cells of hashimatos may cause false positives on cytology if the FNAC is obtained from such benign nodule –> so, we would recommend that you choose ultrasound as your next step if that is there in your MCQ choices. If the choices have no ultrasound, choose FNAC as answer). Further approach will depend on FNAC results. For hypothyroidism issue – Treat with levothyroxine if overt hypothyroidism or if subclinical hypothyroidism that warrants treatment.
b) If TSH normal – suggests cold nodule – next step, get FNAC.
c) If TSH low – suggests Hot nodule ( toxic adenoma) but not confirmative (What if there is GRAVES in the surrounding tissue and this is a cold nodule?) – so, next step get RAIU scan. If RAIU scan shows Hot nodule treat with I131 ( if there is overt hyperthyroidism from this toxic adenoma) or just observation. If RAIU shows COLD nodule, get FNAC.

Further Approach depends on FNAC results :
a) If FNAC is benign – Suppressive therapy with LT4 in some cases if cosmetically warranted
b) If FNAC is malignant/ suspicious – SURGERY
c) If FNAC is non-diagnostic – repeat FNAC. If repeat FNAC is again non-diagnosotic, surgery
F. Partial thyroidectomy + life long levothyroxine


ETHIC

A 17-year-old girl comes to the office for a complete physical examination before going off to college. You have been the physician for her and her brother since birth, and for both her parents for the past 20 years. The patient has been very healthy and has had all of her immunizations. Her mother is always in the waiting room as you obtain the history and perform the physical examination. The patient admits to you that she has had her first sexual experience after the prom a few weeks ago. After she tells you this she becomes very worried that you will tell her mother. At this time you should


A. advise her to tell her mother herself so you will not have to tell her
B. explain that you will not bring up the issue but that you cannot lie if the mother specifically asks if her daughter is sexually active
C. perform a pelvic examination and obtain a Pap smear specimen
D. tell the patient that your conversations with her will remain confidential
E. try to convince her to talk about these issues with her mother.

answer is D


" In establishing and maintaining a good physician-adolescent relationship, the physician should tell the patient that their conversations will remain confidential. This way, the adolescent will be able to trust the physician and will be willing to discuss issues, such as sexuality, that they do not want their parents to know about, but that may affect their health.

An exception to the confidentiality rule is the duty to warn and protect a third party from violence or infectious conditions, such as tuberculosis and syphilis
MED 36
A 25 year old woman presents to your office with history of genital lesions. The patient says that she has has read about genital warts on the internet and is now very concerned that she might be suffering from the same. She is sexually active with her boyfriend and does not want him to get infected with her condition. Physical examination reveals lesions that are are flesh-colored, soft pearly papules found on the inner aspects of labia minora which are symmetrically distributed on either side of the vulva and are easily seperable from each other.
A) Topical Imiquimod

B) Trichloroacetic Acid

C) Treat both patient and her partner with Podophyllin

D) Re-assurance

E) Oral Acyclovir



Answer is D

Vestibular Papillae are common benign lesions that are often mistaken as genital warts and cause unnecessary concern to the patients. So, questions like these are often high yield on the USMLE. Vestibular papillomatosis is a normal vulvar anatomical condition. It is a female counterpart of male pearly penile papules. A correct diagnosis is important and prevents unnecessary stress to the patient.


Vestibular papillae are flesh-colored, soft pearly papules found on the inner aspects of labia minora. They are usually symmetrically distributed on either side of the vulva and can be easily separated from each other on examination.

On the other hand, genital warts are not confined to the vestibule. The cauliflower or filiform projections of genital warts tend to fuse at the base and cannot be seperated easily.

Acetic acid test : When 5% acetic acid is applied to condyloma acuminatum, a whitening occurs. There is usually no whitening with Vestibular papillae

" if there is clinical confusion between vestibular papillae and warts, "acetic acid test" can be used to differentiate"

Acetic acid test : When 5% acetic acid is applied to condyloma acuminatum, a whitening occurs. There is usually no whitening with Vestibular papillae
MED 36
Sam is a 35 y/o alcoholic who is brought to the ER in a comatose state. Sam’s wife tells you that she had an argument in the evening about 5 hrs ago over Sam’s alcohol habits. Sam apparently got mad over the discussion, drove his car and returned an hour ago in a very intoxicated state. Wife called the EMS and rushed him to the ER. On examination Sam is disoriented and hallucinating , Pulse 120 Tm 99, RR 26 BP 126/76. The rest of the physical exam is normal except for stuporos state and alcohol smell. Lab studies revealed Na 130 k 3.4 cl- 95 Hco3 16, Glucose 90 Creatinine 1.6 BUN 45. Blood Ethylalcohol level was 180. Serum osmolarity was 360mg%. ABGs revealed 7.28, Pco2 28, Po2 76 Sao2 93. The next best step in management ?

A) Endotracheal intubation in view of severe acidosis
B) Hemodialysis because this is an acute renal failure causing acidosis
C) Fomepizole because of suspicion of ethylene glycol intoxication
D) Supportive treatment for now because this is an ethylalcohol induced lactic acidosis
E) Bicarbonate drip to reverse the acidosis because this is renal tubular acidosis

ANSWER IS C
MED ETHIC 2

q ....Lisa was one of your patients 2 years ago. While Lisa was in NJ she has been your regular patient for her depression. She trusts and respects you a lot. She even told you earlier that she would be very lucky if she could date a person like you at least once in her lifetime. She is a beautiful 25 year old whom any man would like at a first sight. You have lost contact with Lisa and she has not been your patient for past 2 years because she moved to Florida. She happens to meet you incidentally at a mall and requests that you go for a date with her the following weekend. Your response should be:

A) Tell her that since she no longer your patient you can get involved with her.
B) Refuse her proposal because its not ethical for you to do it
C) Tell her you could go for a dinner this weekend but you will not get sexually involved as that part is unethical
D) Tell her its not appropriate for her to make such advances towards her past physician
E) Tell her you would definitely get involved with her provided she signs a paper releasing you from any liability
Ans.is b

given answer is b
there is no cut-off for past physician


“A sexual relationship with a former patient is unethical if the doctor "uses or exploits the trust, knowledge, emotions or influence derived from the previous professional relationship."
this patient has trust derived from previous relationship
MED 22

A 46-year-old fisherman and Vietnam veteran presented with a recurrent rash on his arms and legs and a painful, swollen area on his left leg of several days’ duration. The rash had been a problem for about two years and was treated with several courses of antibiotics for cellulitis. The patient reported that for the past two years his skin had been prone to blister and tear with minor trauma and that at times his urine appeared to be dark reddish in color. On examination, he had a slight fever and an area of cellulitis on his left leg. His face was erythematous. On his hands, arms, and legs were vesicles and small bullae, some crusted lesions, and hypopigmented and hyperpigmented macules. What is the most important next step in diagnosis?

A. ANA

B. Rheumatoid factor

C. Skin biopsy

D. Hepatitis C serology

E. Hepatitis B serology
Ans. C



PCT is due to a defective enzyme (uroporphyrinogen decarboxylase) in liver . ( the enzyme is involved in hem synthesis)
PCT begins in mid-adult life especially after exposure to substances that increase the production of porphyrins (precursors of haem) in the liver such as alcohol, estrogen e.g. oral contraceptive, hormone replacement or liver disease
Clinical features include Sores (erosions) following relatively minor injuries, Fluid filled blisters (vesicles and bullae) and Increased sensitivity to the sun
Characteristically, the urine is darker than usual, with a reddish or tea-coloured hue

If asked on the exam, consider the diagnosis of Hepatitis C infection ( important association).

DX – Elevated urinary porphyrins, wood’s light on urine gives marked fluorescence

RX
Avoid alcohol
Use tanning creams in sun and avoid sun in acute flare.
Discontinue estrogens
Therapeutic phlebotomy to reduce iron stores (this improves heme synthesis disturbed by ferroinhibition of UROD. )
In patients in whom phlebotomy is not convenient or is contraindicated and in those who have relatively mild iron overload --> use oral chloroquine phosphate (or ) hydroxychloroquine sulfate

MED 51

Q69) You are treating an 18-year-old white male college freshman for allergic rhinitis. It is September and he tells you that he has severe symptoms every autumn, which impair his academic performance. He has a strongly positive family history of atopic dermatitis. Which one of the following is the most appropriate management?

a) Intranasal decongestants

b) Intranasal glucocorticoids

c) Intranasal cromolym sodium

d) Intranasal antihistamine

e) RAST testing

answer and drug of choice is intranasal steroids.

Topical intranasal glucocorticoids are currently believed to be the most efficacious medications for the treatment of allergic rhinitis. They are far superior to oral preparations in terms of safety.

Cromolyn sodium is also an effective topical agent for allergic rhinitis; however, it is more effective if started prior to the season of peak symptoms.

Because of the high risk of rhinitis medicamentosa with chronic use of topical decongestants, these agents have limited usefulness in the treatment of allergic rhinitis.

Some of the newer oral antihistamines have been found to be comparable in efficacy to intranasal steroids, but their use slightly increases the incidence of adverse effects and drug interactions. They are not as useful for congestion as they are for sneezing, pruritis, and rhinorrhea. Newer agents are relatively free of sedation. Overall, they are not as effective as topical glucocorticoids. Azelastine , an intranasal antihistamine, is effective in controlling symptoms but can cause somnolence and has a very bitter taste.

In case of Infective Endocarditis, most often questions are on Prophylaxis – where to give it? How do you decide? What advise will you give patient etc!!

In case of IE prophylaxis, First determine if the patient has a cardiac condition that puts him at HIGH risk for IE or not and then determine whether the planned procedure presents a significant risk of bacteremia with organisms known to cause IE.

As per AHA (2007) guidelines, IE prophylaxis is recommended only in HIGH RISK cardiac conditions prior to high risk dental procedures alone. No prophylaxis is recommended for Moderate risk cardiac conditions (i.e; Rheumatic Heart Disease, MS, MR, MVP with MR, VSD, AS are no longer an indication for IE prophylaxis prior to ANY procedure!)

As per AHA-2007 guidelines, No prophylaxis is recommended in ANY cardiac condition prior to GI/ GU procedures


Cardiac Conditions Associated with Endocarditis - Endocarditis prophylaxis recommended in these High-risk categories
- Prosthetic cardiac valves,bioprosthetic and homograft valves
- Previous bacterial endocarditis
- Complex cyanotic congenital heart disease (e.g., single ventricle states, transposition of the great arteries, tetralogy of Fallot)
- Surgically constructed systemic pulmonary shunts or conduits


Endocarditis prophylaxis not recommended in the following Moderate and low risk categories :=

- Most other congenital cardiac malformations (other than above and below)
- Acquired valvar dysfunction (e.g., rheumatic heart disease)
- Hypertrophic cardiomyopathy
- Mitral valve prolapse with valvar regurgitation and/or thickened leaflets
- Isolated secundum atrial septal defect
- Surgical repair of atrial septal defect
ventricular septal defect, or patent ductus arteriosus (without residua beyond 6 months)
- Previous coronary artery bypass graft surgery
- Mitral valve prolapse without valvar regurgitation
- Previous rheumatic fever without valvar dysfunction
- Cardiac pacemakers (intravascular and epicardial) and implanted
MED 28

A 55 y/o woman with history of well controlled DM Type II presents for her regular follow-up visit. She has no new complaints. She has been well controlled on Metformin alone with a hemoglobin A1c of 6.5. The patient is afebrile with a B.P 96/72, HR 88, RR 16. Physical examination is benign except for decreased sensation in her bilateral lower extremities consistent with diabetic neuropathy and bilater lower extremity edema. Her last urinary microalbumin about one year ago was negative. A repeat dipstick test now is positive for protein and blood but negative for leucoesterase and nitrite. Subsequent urine microscopy reveals 4 dysmorphic RBCs/HPF and red cell casts. Labs reveal elevated serum creatinine at 1.4 as opposed to her baseline creatinine of 0.8 6 months ago. The next important step in approaching this patient’s Renal Insufficiency is:

A) Obtain CPK level
B) 24 hour urine for microalbumin
C) Start ACE inhibitor
D) Repeat urinalysis in 3 months
E) Referral to Nephrologist and Renal biopsy
F) Start emperic antibiotic therapy for UTI
Ans. E.

The presence of red cell casts indicate glomerular origin of this patient’s hematuria. Etiologies include various glomerulonephritis and hence, a renal biopsy is warranted. A nephrotic syndrome that is expected with Diabetic nephropathy should not have dysmorphic red cells or red cell casts in urine. Presence of these indicates Nephritis but not nephrotic syndrome.

A. is not the answer because here a positive dipstick is also followed by a positive urinalysis indicating true hematuria. A myoglobinuria will have positive dipstick but no RBCs on urine microscopy.

B. is not the answer because it does not add anything to elucidate the cause of this patient’s hematuria. In view of concomitant presence of RBC casts, this patient’s acute onset protein in the urine may be secondary to glomerulonephritis rather than DM nephropathy.

C. Presence of RBC casts indicate glomerual cause of hematuria. So, the patient should be referred to a nephrologist rather than a urologist

D. Repeating urinalysis in 3 months is appropriate for a new microscopic hematuria with out any features suggesting kidney involvement. Here hematuria is clearly glomerular in origin and requires further work up as soon as possible.

F. Is incorrect because this patient has no evidence of UTI. The patient’s clinical features as well as urinalysis findings do not suggest a UTI. The patient has no fever or dysuria. Dipstick is negative for leucoesterase or nitrite. Urinalysis has no WBCs or WBC casts. Absence of all these make UTI an unlikely etiology of her hematuria.



Therapy of Hypernatremia : -

First, consider the following :
a) Hemodynamic problem or just osmolal problem?
b) Acute or chronic problem?
c) Prior losses and present losses of fluid ?
d) Rate of correction?
Acute: 1-1.5 meq/L/hour reduction
Chronic: 0.5 meq/L/hour reduction or 50% within first 24hours

e) WHICH FLUID TO USE ?

1) Isovolemic ( No signs of hemodynamic instability or hypovolemia)

Rx: Free water: PO water or intravenous D5W slowly if patient can not take PO
Water deficit = 0.6 (BWKg) x (Pna/140 -1)

2) Hypovolemic – unstable pt? or any other physical exam ( orthostatic hypotension, dizziness on standing) findings to suggest hypovolemia? Any lab abnormalities suggesting hypovolemia ( concentrated urine? BUN/ Crea ratio > 20:1 ) . In these cases, Rx :

**Correct volume problem first i.e. normal saline
** Then, Correct osmolal problem.
** Even if seizures or coma are present, volume problem must be corrected first in hypovolemic cases ( remember ABC - "c" for circulation first). In hypovolemic hypernatremia cases, use normal saline to correct hypovolemia first and since, large volumes of NS (osmolality of 308) is often infused in this setting, serum Na+ is usually corrected slowly.

3) Hypervolemic ( signs of hypervolemia such as increased JVD, crepitations suggesting pulmonary edema)

Rx: Salt removal with loop diuretics and free water

A 25-year-old woman with mild-intermittent asthma comes for a follow-up office visit. The patient is 8 weeks pregnant. Before the pregnancy, her asthma had been adequately controlled by avoiding exacerbating factors and using an albuterol metered-dose inhaler as needed. She typically had daytime symptoms two to three times each month and rarely had nocturnal symptoms. Since becoming pregnant, she is having wheezing two to three times each week and dyspnea causing nocturnal awakenings two to three times each month. Albuterol, 2 puffs by metered-dose inhaler, provides immediate relief, and the symptoms are not interfering with her activities. She has no other symptoms, and her only other medication is a prenatal vitamin. Office spirometry 3 months ago was normal. Personal-best peak expiratory flow rate (PEFR) was 500 L/min.

On physical examination, temperature is 36.8 °C (98.2 °F), blood pressure is 110/66 mm Hg, pulse rate is 89/min, and respiration rate is 20/min. The lungs are clear during normal and forced expiration, and the remainder of the examination is normal. Office PEFRs (L/min) are 400, 410, and 400.

In addition to beginning an asthma action plan, which of the following is the most appropriate management at this time?
A Add budesonide
B Add montelukast
C Add salmeterol
D Increase albuterol to scheduled use, 2 puffs every 4 hours



A

Key recommendations from the guidelines regarding medications include:

* Albuterol, a short-acting inhaled beta2-agonist, should be used as a quick-relief medication to treat asthma symptoms. Pregnant women with asthma should have this medication available at all times.

* Women who have symptoms at least two days a week or two nights a month have persistent asthma and need daily medication for long-term care of their asthma and to prevent exacerbations. Inhaled corticosteroids are the preferred medication to control the underlying inflammation in pregnant women with persistent asthma. The guidelines note that there are more data on the safety of budesonide use during pregnancy than on other inhaled corticosteroids; however, there are no data indicating that other inhaled corticosteroids are unsafe during pregnancy, and other inhaled corticosteroids may be continued if they effectively control a patient’s asthma. Alternative daily medications are leukotriene receptor antagonists, cromolyn, or theophylline.

* For patients whose persistent asthma is not well controlled on low doses of inhaled corticosteroids alone, the guidelines recommend either increasing the dose of inhaled corticosteroid or adding another medication — a long-acting beta agonist. The expert panel concluded that data are insufficient to indicate a preference of one option over the other.

* Oral corticosteroids may be required for the treatment of severe asthma. The guidelines note that there are conflicting data regarding the safety of oral corticiosteroids during pregnancy; however, severe, uncontrolled asthma poses a definite risk to the mother and fetus; and use of oral corticosteroids may be warranted.

MED 47

Q64) A 44 year old man presents to your office with pain and swelling of the small joints in his hands and wrists. The symptoms have been progressing over the past 4 months. He denies any fever or weightloss. He reports stiffness in his both hands that occurs every morning and lasts for 2 hours. On examination, he has symmetrical involvement of both wrists and proximal interphalangeal joints. The involved joints are swollen and tender. Laboratory tests shows high ESR, negative rheumatoid factor, and a positive anti-CCP antibody. X-ray of the wrist and hands reveal erosions in the proximal phalanges and ulnar styloid process. The most appropriate next step in management :

A. Prednisone
B. Start NSAID and follow-up in one month.
C. Start NSAID and Methotrexate
D. Start Infliximab
E. Start NSAID and Hydroxychloroqui

Ans. C
This patient has severe rheumatoid arthritis. He has all the criteria for the diagnosis of RA ( morning stiffness GREATER THAN 1hr, symmetricity, hand joint involvement, more than 3 joints, +ve CCP and bony erosions). His disease can be classified as "severe" because he has high ESR, high CCP and most importantly, he has erosive bony disease.

Therapy depends on severity at the time of diagnosis ( in early RA) :-
Mild RA : NSAID alone can be started first. NSAID does not prevent disease progression or erosive bone disease. If symptoms persist or progress while on NSAIDS or if no remission occurs after six weeks on NSAID therapy, a disease modifying agent must be added ( DMARD). For mild disease, a less toxic DMARD such as Hydroxychloroquine or Sulfasalazine must be used initially ( not methotrexate).

Moderate RA : NSAID + less toxic DMARD such as hydroxychloroquine should be started from the time of diagnosis.

Severe RA : An NSAID along with a more potent DMARD such as Methotrexate should be started together as initial therapy. NSAID alone should not be used as sole therapy in severe RA as it will not prevent disease progression. In patients who can not be started on MTX ( for contraindications), a TNF alpha inhibitor such as leflunomide or etanercept must be started as initial DMARD.

Ans. A is incorrect. Prednisone is usually used for treating RA flares.

Ans. B is incorrect. This option is appropriate if the patient is determined to have early, mild RA. Patients can be started on NSAID alone and follow up in 1 month to see if there is remision. If disease is still present, DMARD must be added.

Ans. D is incorrect. This option is correct if the patient is determined to have early, severe RA and if the patient can not be started on DMARD such as methotrexate

Ans. E is incorrect. This option is appropriate if the patient is determined to have early, mild RA or moderate RA. Patients can be started on NSAID alone in mild RA and follow up in 1 month to see if there is remision. If THE disease is still present, a mildly toxic DMARD must be added
such as hydroxychloroquine or sulfasalazine.

Q69) You are treating an 18-year-old white male college freshman for allergic rhinitis. It is September and he tells you that he has severe symptoms every autumn, which impair his academic performance. He has a strongly positive family history of atopic dermatitis. Which one of the following is the most appropriate management?

a) Intranasal decongestants

b) Intranasal glucocorticoids

c) Intranasal cromolym sodium

d) Intranasal antihistamine

e) RAST testing

answer and drug of choice is intranasal steroids.


Topical intranasal glucocorticoids are currently believed to be the most efficacious medications for the treatment of allergic rhinitis. They are far superior to oral preparations in terms of safety.

Cromolyn sodium is also an effective topical agent for allergic rhinitis; however, it is more effective if started prior to the season of peak symptoms.

Because of the high risk of rhinitis medicamentosa with chronic use of topical decongestants, these agents have limited usefulness in the treatment of allergic rhinitis.

Some of the newer oral antihistamines have been found to be comparable in efficacy to intranasal steroids, but their use slightly increases the incidence of adverse effects and drug interactions. They are not as useful for congestion as they are for sneezing, pruritis, and rhinorrhea. Newer agents are relatively free of sedation. Overall, they are not as effective as topical glucocorticoids. Azelastine , an intranasal antihistamine, is effective in controlling symptoms but can cause somnolence and has a very bitter taste.

Below is the score to help in management of acute pharyngitis in office. This helps to decide on probability of streptococcal sore throat.

Original Criteria (interpretation below based on these) - 1 point for each

1. Tonsillar exudate
2. Tender, anterior cervical adenopathy
3. Cough absent
4. Fever present
Modifiers : Age younger than 15 years: +1 point, Age 15 to 45 years: 0 points & Age over 45 years: -1 points

Now, how will you approach a pharyngitis or sore throat ?

Strep Score 4 (or Strep Score 2 if patient unreliable) --> Treat with antibiotics.

Strep Score 2 to 3: Perform rapid antigen test
Antigen test positive: Treat with antibiotics
Antigen test negative: Throat Culture (Requires 24 hour minimum for adequate growth ) --> most specific (99%). Sensitivity 90%. Not recommended as primary test due to 24 hour delay . Remember that –ve Rapid strep does not rule out Strep throat.

Strep Score 0 to 1
Provide Pharyngitis Symptomatic Treatment --> salt water gargles, sucking candies, ibuprofen

A 17-year-old Caucasian male presents to an urgent care clinic complaining of severe sunburn to his face and forearms. He was playing touch football outdoors for less than one hour on a relatively overcast day before noticing the sunburn. His past medical history is significant for acne vulgaris, which he is taking medication for. Physical examination reveals numerous comedones, papules, and pustules on his face, neck, and chest. There is significant scarring from previous episodes of acne. Confluent areas of erythema, warmth, and edema are evident on the patient?s face and forearms. . Which of the following medications is the most likely causative agent of the sunburn?
1. Benzoyl peroxide
2. Erythromycin
3. Clindamycin
4. Doxycycline
5. Minocycline

ANSWER 4. Doxycycline


















A 47 year old white male comes to the clinic for a routine physical examination. His past medical history is unremarkable. Although he has no complaints, he appears more anxious than normal. Upon further questioning you learn that the patient's 72 year old father was recently diagnosed with prostate cancer and the patient is concerned that he too might have prostate cancer. No other members of his immediate family have been diagnosed with prostate cancer. The patient did some research on the internet about prostate cancer and says ' I am willing to pay out of my pocket for whatever test is needed to put my mind at ease". He also states that he has not slept in a day and is not performing well at work, worrying about the prostate cancer. He wants to know if he has the disease so that he can grab it early on start treatment while he is young. His physical examination and digital rectal examination are normal.What is the most appropriate course of action?

A. Ask the patient to return to determine the PSA level when he notices urinary symptoms
b. check the patient's PSA level today
c. Reassure the patient that he is at low risk of prostate cancer because of his no symptoms and normal DRE
d. Refer him to a urologist
e. start checking PSA levels and doing annual DRE after age 50
B is the correct answer.
The patient is very anxious and the thought is affecting his daily life. It's good to get the test done now and relieve some of his anxiety.
Otherwise, screening for prostate cancer involves digital rectal examination and a PSA level. That should be done early

A 29-year old man comes to your office for a routine visit. His only complaint is leg pain after walking a three-block distance. He states that six months ago he was able to walk a longer distance without having to stop. His father died of a heart attack at the age of 44. His mother had diabetes mellitus, and she too died of a heart attack at the age of 47. His older brother, who is now 35 years old, had a stroke and underwent a carotid endarterectomy last year.

The patient presents as a thin individual with a blood pressure of 135/70 mm Hg and a heart rate of 78/min. Physical examination findings are remarkable for the presence of multiple xanthelasmas on the face, chest, and upper back. There is bilateral, irregular, firm, and nodular thickening in the Achilles tendons and extensor tendons of the hands. This patient's medications include atorvastatin, gemfibrozil at maximum doses, and niacin, which was added to the regimen six months ago. He is maintaining a fat-free diet and exercises regularly. Laboratory test results show: total cholesterol 815 mg/dL, triglycerides 515 mg/dL, and HDL 55 mg/dL. The level of total cholesterol has increased by 15% since the last visit.

What would you recommend to this patient?

(A) Nutritionist consult
(B) Stress test for detection of silent ischemia
(C) Plasmapheresis
(D) Liver transplantation
(E) Increase the dose of statins as long as transaminases are within the normal range



The treatment of choice for
arrhythmias in patients with a tricyclic overdose is
sodium bicarbonate. Raising the pH and administering
sodium seems to “prime” the sodium channels in
the heart reversing the toxicity of the tricyclic.
Causes of an elevated Lactic acidosis
anion gap acidosis Diabetic ketoacidosis
Ingestions such as ethanol,
methanol, etc
Uremia
Alcoholic ketoacidosis

Causes of a normal GI bicarbonate loss
anion gap acidosis (eg, chronic diarrhea)
Renal tubular acidosis
(types I, II, and IV)
Interstitial renal disease
Ureterosigmoid loop
Acetazolamide and other
ingestions
Small bowel drainage

Always emperic fluconozole. EGD only if clinical worsening or no response.


Esophagitis in AIDS.
Patients present with odynophagia, heartburn or dyshagia.

Etiology : Candida species , Cytomegalovirus, Herpes Simplex Virus, Giant Aphthous ulceration . Most common are Candida, CMV and aphthous esophagitis are most common. HSV is less common.

Clues for finding the etiology on clinical grounds :
a) Candida: oral thrush, diffuse odynophagia/dysphagia, CD4 less than 100, usually no fever.
b) CMV: fever, focal pain, CD4 less than 50.
c) Aphthous: focal odynophagia, no fever & variable CD4.
d) If CD4 more than 200: think of other common non hiv related etiologies - GERD, NSAIDS, pill ulcers (e.g., tetracycline, doxycycline, potassium, iron, bisphosphonates), TB, esophageal cancer, lymphoma.

Approaching AIDS related Dysphagia or Odynophagia:
1. Look for clues as above for likely etiology. However, candida esophagitis is so common in HIV that even in the absence of thrush, first step is always emperic therapy with an azole antifungal.
- The finding of oral candidiasis associated with esophageal symptoms has a positive predictive value of close to 100% for Candida esophagitis. If the patient with odynophagia has associated thrush - think presumptive esophageal candidiasis, start emperic therapy with fluconozole. If there is no clinical response in 5 to 7 days or if there is clinical worsening despite starting azole emperic therapy, proceed with endoscopy and biopsy to rule out other etiologies. If the diagnosis is correct, with empiric treatment, favorable response occurs usually within one to three days. This spares the patient unnecessary endoscopy. However, upper endoscopy should not be delayed in the patient who does not respond.
- On Endoscopy, if there are whitish plaques, no ulcers - think Candida. If there are ulcers, think CMV, aphthous or HSV. HSV ulcers are usually multiple and punched out - biopsy reveal multi nucleate giant cells. CMV ulcers are single and large - biopsy reveals intranuclear inclusions. Aphthous ulcers are sterile on biopsy and cultures.

TREATMENT
Candidiasis - fluconozole x 2 weeks, Cspofungin, amph B are alternatives

CMV : valganciclovir, ganciclovir
HSV: acyclovir or valacyclovir or famciclovir
Aphthous : prednisone 40 mg PO once daily, tapering 10 mg/wk, x 1 mo.
Aphthous (refractory to prednisone): thalidomide

you should only ordert stat orders only if they are needed. He says order it when the patient has severe pain or any other symptom that indicates severe symptomatology. It is mentioned that it is inappropriate to keep the patient waiting in the office for the stat tests when they are not needed.

so the conclusion is

Routine cases :
order only routine tests. Some tests that can be done in the clinic can be ordered stat because they are done in the clinic not in an outside lab. eg: are urine dipstick, blood glucose by glucometer, urine pregnancy test . These tests take less than 5 mins to return

URGENT cases:
order STAT tests and be prepared to treat the symptoms and move the patient to emergency department. Dr.says if you are making a decision to do a STAT test in the office you are already making a clinical decision that you are dealing with a severe condition. So treat the patients emperically and move them to ER after ordering the stat tests in the office itself.

office cases are mostly routine type and you must not keep patient waiting in the office unnecessarily by ordering unnecessary stat tests. As per dr.red in real life, you will devote only 15 mins for a routine problem in the clinic and patient should preferably be out of the clinic with in 30 mins. dr.red also says that since you will not have the diagnosis on day 1, you must start treating the symptom right away until you get the result back, Once the results appear on the screen, you should choose "stop the clock" , put in the treatmentorders and then move ahead to reschedule the appointment. That means you can give necessary oral treatment to the patient by accessing the order sheet even when the patient is at home, you should not wait for the patient to return to clinic if the treatment need be started ---- stop the clock and start treatment by going to order sheet as long as treatment is oral.

i am unable to put it in words but when you practice on the software you will understand better. If you can, manage watch dr.red's videos or the live workshop. It is better to understand when you watch the demonstratuons.

for diagnostic tests it is either stat or routine.
Try these on primum software (These report times are totally wrong in UW interactive software so dont get confused) , take case 2 example on primum software.... order a CT head STAT in the office it will take 4 hours. Move the patient to ER and order CT head STAT again. It takes only 30 mins in the ER. Same with even a simple test like CBC - cbc STAT takes 1 hour in the office setting and now, move the patient to ER and order same cbc in the ER, it takes only 30 minutes. So same "stat" order comes back at different times depending on the location.

That is what Dr. meant when he said if a patient had severe symptomatology you are already making a decision to move the patient to the ER and then order tests as STAT because when tests are ordered in the ER as STAT they come much quicker... this time difference can be life saving in patients with stroke or acute STEMI, PE etc

" keeping the simulated time low is the secret of very high score in unstable case scenarios " I took this golden sentence from one of the question logs.
If an office case is unstable ordering STAT tests while keeping the patient in office still wastes the patient time or simulated time. This can lead to failure on the case sometimes. If an office case is unstable, give stabilizing treatmen first, move to the ER and then only order STAT tests.

Dr. gave this example to us to illustrate this point : If a patient came to the office with CVA like symptoms and if we order CT head in the office STAT, it takes 4 hours and we will lose the golden opportunity to administer the thrombolytics because we can not give tpa until CT head comes negative for bleed. If CT head comes after 4 hours, we lose the 3 hour window for the tpa. So the correct approach is if the patient came to the office with CVA like symptoms, move the patient STAT to the ER and then order a STAT CT HEAD. This comes in 30 minutes and if it shows no bleed, can give tpa. In the first approach, simulated time is 4 hrs by the time an important intervention can be made. In the second approach, simulated time is 30 mins by the time intervention is made. First approach will cause you to fail on this case as you can not give tpa beyond 3 hrs in a CVA case. Second approach will be scored very highly as you addressed the patient as recommended in the guidelines with in just 30 minutes of simulated time.
Simulated time is the KEY of high scoring here!

UW ccs case hyperthroidism,being an office case it says to wait for the TSH and T3,T4 levels,RAIU.so that means u send the patient home with palpitation and wait for the results even to start B blocker.

should not wait for TSH to start a beta blocker. Treat symptoms at first clinic visit until diagnosis is clear. If palpitations are present and clinically hyperthyroid, start beta blocker. Send patient home and schedule appointment. Wait for TSH first. If TSH comes low, stop the clock and go to order sheet even though patient is at home --- then put free t4, t3, reschedule appointment and when patient comes to next visit, work up further RAIU scan and start proplythiouracil ( dr.red ccs)
Do the rectal exam. Take the case 1 or 2 for example on primum and do rectal exam. In the exam findings, they will say no occult blood. Take case 3 and do rectal exam, there they say occult blood positive. That means guaic is automatic when rectal is done.

In a doctor's office or ER, a rectal exam always includes Occult blood testing with a guiac card unless there is no stool sample. The reasons for doing rectal exam are mainly to do occult blood ( fobt) and to feel prostate.

FOBT is patient based. Guaic card is given to the patient and ask them to get three samples and this is interpreted in lab.
Statins are contraindicated in pregnancy. It is a pregnancy category X drug.
Cholesterol biosynthesis may be important in fetal development. Should not interfere.

Administer to women of childbearing potential only when conception is highly unlikely and patients have been informed of potential hazards.



Drug ratings in pregnancy
Category Interpretation
A Controlled studies show no risk
Controlled studies in pregnant women fail to demonstrate a risk to the fetus in the first trimester with no evidence of risk in later trimesters. The possibility of fetal harm appears remote.
B No evidence of risk in humans
Either animal-reproduction studies have not demonstrated a fetal risk but there are no controlled studies in pregnant women, or animal-reproduction studies have shown an adverse effect (other than a decrease in fertility) that was not confirmed in controlled studies in women in the first trimester and there is no evidence of a risk in later trimesters.
C Risk cannot be ruled out
Either studies in animals have revealed adverse effects on the fetus (teratogenic or embryocidal effects or other) and there are no controlled studies in women, or studies in women and animals are not available. Drugs should be given only if the potential benefits justify the potential risk to the fetus.
D Positive evidence of risk
There is positive evidence of human fetal risk, but the benefits from use in pregnant women may be acceptable despite the risk (eg, if the drug is needed in a life-threatening situation or for a serious disease for which safer drugs cannot be used or are ineffective).

X Contraindicated in pregnancy
Studies in animals or human beings have demonstrated fetal abnormalities or there is evidence of fetal risk based on human experience, or both, and the risk of the use of the drug in pregnant women clearly outweighs any possible benefit. The drug is contraindicated in women who are or may become pregnant.

MEDICINE 57

76) A 65 year-old man with history of recently diagnosed metastatic colon cancer being treated with chemotherapy is admitted to the hospital with constipation and vomiting. His colon cancer was diagnosed by colonoscopy 2 months ago when he presented with massive GI bleeding. At this admission, patient is diagnosed with bowel obstruction secondary to descending colon cancer and underwent a palliative left hemicolectomy to provide symptomatic relief. He has no occult or gross GI bleeding at this time. On the sixth post-operative day, you are called by the nurse because the patient’s blood pressure is 80/40. His heart rate is 82, respiratory rate 24 and temperature of 100.6. The patient is given Normal saline bolus. A CXR is normal. EKG reveals a prominent S wave in lead I, a Q wave and inverted T wave in lead III. Of note, a pre-operative EKG was completely normal. First set of cardiac enzymes are negative. A bedside 2D echo reveals global hypokinesis of the right ventricle. A repeat blood pressure obtained after normal saline bolus is still low at 70/40. The most likely etiology of the shock in this patient is :

A) Hypovolemia
B) Septic shock
C) Acute myocardial infarction leading to cardiogenic shock
D) Acute pulmonary embolism
E) Tension Pneumothorax

77) Most important next step in treating this patient’s shock?

A) Continued fluid boluses
B) Antibiotics and pressor support with dopamine
C) Intra-aortic balloon counter-pulsation followed by urgent cardiac catheterization.
D) Anticoagulation with heparin
E) Tissue plasminogen activator ( tpA)
F) Embolectomy
G) Chest tube placement.
H) Inferior vena cava filter

78) The patient was appropriately treated. The discharge recommendations should include :
A) Inferior venacava filter
B) Life-long low-molecular weight heparin
C) Life-long coumadin
D) Hypercoagulability testing
E) Compression stockings

Q76) D. Q77) F Q78) B.

Q76) D
Pulmonary embolism is a common complication that can occur in post-surgical patients, usually after post-operative day 5.
The patient has a very high risk profile for pulmonary embolism. The clinical probability of the PE from his history is extremely high – age greater than 60 years, cancer, immobilization and surgery with in last few days are well known risk factors for pumonary embolism which this patient clearly possess. Also, sudden appearance of right ventricular strain pattern (S1Q3T3) and a classic acute corpulmonale findings on 2D Echo suggests that PE is the most underlying etiology for this patient’s shock. ( Obstructive type shock)
Although. all the other choices are potential causes for shock in the above patient, their probability can be reduced by considering and analyzing important clues in the question.

- Choice A not correct – Failure to respond to normal saline indicates that this is not hypovolemia. Also, hypovolemic shock should not produce acute right ventricular strain on the EKG or hypokinesis on the 2D Echo.

- Choice B not correct – Fever may suggest sepsis but it needs to be remembered that fever can also be seen with PE. Also, septic shock should not produce acute right ventricular strain on the EKG or acute right ventricular hypokinesis alone on the 2D Echo.

- Choice C not correct – Acute MI is a possiblity but it usually produces segmental hypokinesis rather than global hypokinesis on 2D Echo. The cardiac enzymes are also negative.

- Choice E not correct since CXR was normal.




Q77) F.
Pulmonary embolectomy is the correct choice. In scenarios where thrombolysis is contraindicated, embolectomy is used for patients with PE who are hypotensive despite supportive measures (persistent systolic BP less than 90 mm Hg after fluid therapy and O2) i.e; hemodynamically unstable PE.
The patient has obstructive shock and obstruction should be removed urgently to restore the blood pressure. Clot can be lysed by thrombolysis or mechanically with embolectomy. The patient had GI bleeding in last 6 months which is an absolute contraindication to thrombolysis and also, surgery 6 days ago which is a relative contraindication for tpa. Hence, embolectomy is the choice.

Choice A – not correct – this is the treatment of hypovolemic shock. Hypovolemic shock is unlikely because of the above mentioned reasons in this patient.

Choice B – not correct – this is the treatment of septic shock. Septic shock is unlikely because of the above mentioned reasons in this patient.

Choice C – not correct – this is the treatment of cardiogenic shock. Cardiogenic shock is unlikely because of the above mentioned reasons in this patient.

Choice D – not correct – this is the treatment of stable pulmonary embolism. In unstable pulmonary embolism, clot obstruction must be relieved rapidly with thrombolysis or embolectomy. If tpa is planned, Heparin should only be started 24 hours after thrombolytics. Heparin will help in preventing further clot extension or further embolism but will not help in immediately treating the obstructive shock.

Choice E – not correct – The patient has contraindications for tpa ( thrombolytics).

Absolute contraindications to thrombolytics include prior hemorrhagic stroke, ischemic stroke within 1 yr, active external or internal bleeding from any source, intracranial injury or surgery within 2 mo, intracranial tumor, GI bleeding within 6 mo, and CPR.
Relative contraindications include recent surgery (less than 10 days), hemorrhagic diathesis (as in hepatic insufficiency), pregnancy, current use of anticoagulants and an INR more than 2, punctures of large noncompressible veins (eg, subclavian or internal jugular veins), recent femoral artery catheterization (eg, less than 10 days), peptic ulcer disease or other conditions that increase the risk of bleeding, and severe hypertension (systolic BP more than 180 or diastolic BP more than 110 mm Hg).

Choice G – not correct – This is the treatment for tension pneumothorax. Tension pneumothorax is an important cause of obstructive shock but a normak CXR rules it out.

Choice H – not correct – this is the treatment for pulmonary embolism or DVT in the presence of contraindications to anticoagulation with heparin or warfarin or in cases of warfarin failure.


Indications for IVC filters:
- Contraindications to anticoagulation
- Recurrent DVT (or pulmonary emboli) despite adequate anticoagulation ( i.e; warfarin failure)
- In patients with low cardio-pulmonary function and extensive DVT ( extending in to inferior venacava) – where any additional small pulmonary emboli may compromise their cardio-pulmonary status further.




Q5) B.
LMWH is superior to warfarin in preventing venos thromboembolism in cancer patients. This has been proven in several studies. Cancer is a hypercoagulable condition and this patient hence, requires life-long anticoagulation.

Choice A is incorrect. IVC filter is indicated for thromboembolism prophylaxis in the presence of absolute contraindication to anticoagulation. The patient has no active bleeding. Also, IVC filter can only protect against PE but not against DVT .

Choice C is incorrect because LMWH is superior to warfarin in cancer patients.

Choice D is incorrect – the patient already has a known hypercoagulable state which is a cancer and requires life long anticoagulation with LMWH. This is not a idiopathic PE where full hypercoagulability work-up would be warranted.

Choice E is incorrect – compression stockings are more effective for preventing calf than proximal DVT and thus, provides inadequate prevention. Also, they are contraindicated in patients with active DVT or those with possible occult DVT as compression can dislodge the clots and lead to PE in those with active DVT.
MEDICINE 58

Q83) 35-year-old man with a 10-year history of type 1 diabetes mellitus is evaluated because of recent onset of morning hyperglycemia. His home blood sugar logs over the last 10 days have consistently been showing elevated sugars in the range of 220 to 300 mg% in the early morning ( pre-breakfast). He has also experienced nightmares recently. He has been compliant with his diet instructions and has not changed his dinner potions recently. He takes mixed insulin regimen : NPH/Regular insulin 70/30 mix at 30 units in the AM before breakfast and 20 units in PM 30 minutes before dinner. Which of the following best explains this patient’s morning hyperglycemia?

( A ) Diabetic nephropathy

( B ) Undertreatment with insulin

( C ) Overtreatment with insulin

( D ) Insulinoma

(E) Non compliance with Insulin



Q84) The best diagnostic study in establishing the diagnosis in this patient :

A) C-Peptide level

B) Urine 24 hour catecholamines

C) Check pre-dinner blood sugar level

D) Check blood sugar level 30 minutes post – dinner

E) Check blood sugar level between 2:00 AM and 3:00 AM



Q85) Next best step in managing this patient’s pre-breakfast hyperglycemia :

A) Increase pre-breakfast regular insulin dosage in AM

B) Increase pre-dinner regular insulin dose

C) Reduce pre-dinner NPH insulin dose

D) Decrease the carbohydrate consumption in the night

E) Discontinue Pre-dinner insulin

83: over treatment (C)
84: check BP at 2 - 3 AM (E)
85: reduce pre dinner insulin (C)

Patient is suffering of simogyi effect due to nightmares and early morning hyperglycemia.

MEDICINE 60

74) A 75 year-old man with history of hypertension presents to the emergency room with complaints of shortness of breath and palpitations. His vital reveal a heart rate 142/min, blood pressure 130/86, temperature 98.6 and oxygen saturation of 89% on room air. On auscultation, there are no rhonchii or crepitations, the heart rate was irregular and rapid with out any murmurs. The patient is placed on oxygen by nasal cannula. An urgent EKG is obtained which reveals rapid atrial fibrillation with no evidence of significant ST-T changes. The patient is started on diltiazem. Chest x-ray is normal and a brain natriuretic peptide is 80ng/L. Electrolytes, TSH and complete blood count are with in normal limits. Cardiac enzymes are drawn. Arterial blood gases reveal a pH of 7.48, po2 of 58, pco2 of 20 on room air ( Fio2 of 21%). The next step in establishing the etiology of his atrial fibrillation :

A) Cardiac catheterization
B) Spiral CT scan of the chest
C) Venos doppler of lower extremities
D) 2D Echocardiogram
E) D-Dimer

75) What is the most likely etiology of atrial fibrillation in Case 1?

A) Acute ST elevation MI
B) Acute pulmonary embolism
C) Pneumothorax
D) COPD exacerbation
E) Congestive heart failure

Ans. D and B

Q74) Ans. D
- 2D echocardiogram in this case will help to evaluate for different etiologies of atrial fibrillation such as acute MI, acute PE and valvular heart disease. From the question, we understand that hypoxia could have possibly initiated the atrial fibrillation. A normal CXR rules out gross lung pathologies such as emphysema, pneumothorax, ARDS, pulmonary edema and pneumonia which could be various etiologies of hypoxia. However, pulmonary embolism and acute MI can not be readily eliminated from a normal Chest X-ray. Hence, a quick bed side echo should be considered. If the Echo reveals segmental hypokinesis of right ventricle, this favors the diagnosis of Acute MI where as if it revealed a global hypokinesis of the right ventricle, it would more favor a diagnosis of acute pulmonary embolism.
- Spiral CT scan is a close distractor here since one may choose this considering the strong diagnosis of pulmonary embolism in the above case. However, spiral CT scan will help you to confirm or rule out PE but it does not help you to evaluate for other possible etiologies of atrial fibrillation at the same time. Hence, 2D echo is a superior initial test in the above case.
- Urgent cardiac catheterization should be performed in the presence of ST elevation MI. There is no evidence of ST elevation in the above case.
- Venos doppler of lower extremities should be considered once we are more certain that PE is the most likely etiology and hence, is not an initial test.
- D-Dimer can be used as a screening test for PE when the pre-test probability is low. A low D-dimer combined with a low pre-test probability of PE can be used to rule out PE. While a low D-dimer < 500 may exclude PE, a higher d-dimer is non-specific and does not differentiate between other causes of thromosis such as DIC, presence of arterial thrombi, PE and DVT.


Q75) B.
The presence of Hypoxia, hypocapnia and increased A-a gradient (about 70) with a normal CXR findings in the above question indicates that an Acute Pulmonary Embolus is the most likely diagnosis.
Choice A – is not the answer because the EKG did not reveal any ST elevations.
Choice C – is not the answer since the physical exam revealed normal breath sounds and CXR was normal.
Choice D – is not the answer since the ABGs in the above patient reveal Hypocapnia and increased A-a gradient. Hypercapnia secondary to acute CO2 retention is often a feature of COPD exacerbation. The A-a gradient is usually normal in COPD except in emphysema.
Choice E – a normal CXR, absence of significant CHF physical findings and a BNP ( brain natriuretic peptide) less than 100 virtually rules out Congestive Heart Failure

MEDICINE 62

A 56-year-old man is evaluated in the emergency department because of progressive swelling of the right lower extremity during the previous 5 days and right-sided pleuritic chest pain and dyspnea beginning 1 to 2 hours ago.On physical examination, his temperature is 38.2 °C (100.8 °F), pulse rate is 105/min, respiration rate is 28/min, and blood pressure is 160/80 mm Hg. Cardiac and pulmonary examinations are unremarkable. Arterial blood gases with the patient breathing room air are PO2, 78 mm Hg; PCO2, 30 mm Hg; and pH, 7.48.Electrocardiography shows sinus tachycardia and nonspecific ST-T wave changes, and chest radiography is normal.Ventilation-perfusion scanning shows two unmatched segmental defects. The D-dimer value is three times the upper limit of normal.
Which of the following is the most appropriate course of action?
( A ) Heparin
( B ) Helical computed tomography with contrast
( C ) Noninvasive studies of the lower extremities
( D ) Pulmonary angiography

ANSWER IS A


MEDICINE 63

A 68-year-old man with asthma is evaluated because he needs to use his albuterol inhaler at night once or twice a week after waking up with chest tightness. His forced expiratory volume (FEV) is 2.18 L (65% of predicted) before and 2.62 L(82% of predicted) after inhaled albuterol. Current medications include inhaled fluticasone, 440 μg twice daily, and an albuterol metered-dose inhaler as needed. Which of the following should be done next to better control his symptoms?
( A ) Increase fluticasone to 880 μg twice daily
( B ) Add salmeterol
( C ) Add prednisone
( D ) Add allergen immunotherapy
( E ) Add a long-acting theophylline at bedtime

ANSWER IS B

MEDICINE 64

A 25-year-old woman is evaluated because of a 3-year history of a nonproductive cough. The cough is aggravated by bicycle riding and occasionally awakens her from sleep. During the past year, she experienced two episodes of bronchitis followed by a dry cough persisting for 2 months. The cough worsened when she visited her sister in Alaska. She has seasonal symptoms of watery, runny nose and sneezing. There is no postnasal discharge, nasal congestion, heartburn, weight loss, or night sweats. She does not smoke. Her physical examination and chest radiography are normal. Spirometry shows forced expiratory volume in 1 sec (FEV1) 3.29 L; forced vital capacity (FVC), 4.13 L; and FEV1/FVC ratio of 79%. Which of the following is the best next management step?
( A ) Chest computed tomography
( B ) Bronchoscopy
( C ) Methacholine inhalation challenge testing
( D ) Observation and reassurance
( E ) Therapeutic trial of a proton pump inhibitor

ANSWER IS C


A 26 year old woman has dysmenorrhea that has not responded to treatment with NSAIDs. Her past medical history is significant for migraine without aura and takes Topiramate for prevention of migraine. Her migraines are well prevented now. She is also sexually active and requests contraception. In view of her dysmenorrhea, OC pills have been recommended to her as it serves to address both the issues of contraception as well as her dysmenorrhea. But she tells you that she once read the package insert in the OC pills and also heard from her friends that she should not use OCPs because she has migraine. Her exam does not reveal any neurological deficits. She does not smoke and leads an active lifestyle. Her B.P is 110/70. What is your best recommendation to her?
A. Reassure her and start OC Pills
B. Tell her to use condoms alone
C. Start minipill because OC pills may worsen her headache
D. Start OC pills but switch topiramate to valproic acid to prevent her migraines better


q2 ..
A 25 y/o woman with hx of endometriosis, has had 2 year history of migraines, however, they bother only once or twice a month. Only one of these attacks a month makes her really disabled. She has been started on propranolol 6 months ago and has been headache free for a bout three months. She says she recently started oral contraceptive pills 3 months ago and her headaches have been out of control. She is getting about 3 to 4 episodes of migraines per month now but no aura. Physical exam is normal. What is your next step in management ?
A. Discontinue oral contraceptive pills
B. Switch to OCPills with low dose estrogen
C. Switch to OC pills with high dose estrogen
D. Start Topiramate for prophylaxis of migraine
E. CT head without contrast

q3.

A 35-year-old woman with history of smoking 1 ppd x 15 yrs, comes to you 4 months after beginning OC pills. Shortly after starting OCs, she started experiencing headaches twice a week lasting 12 hours. The headaches are bilateral, throbbing, and accompanied by nausea and sensitivity to light and sound. They are heralded by a 50-minute visual disturbance consisting of a "bright, zigzag lines" and then fades away as the headache begins. Upon questioning, she reports occasional similar headaches prior to OC use but they were not this bad and never had visual disturbances earlier. Her physical examination is normal. She is sexually active with one partner and desires effective contraception. Her partner does not like using condoms. The next step in management?
A. Reduce the dose of estrogen in the combination pill
B. Switch to mini pill
C. Ask her to convince her partner to use condoms
D. Reassure her and continue OC Pills
E. Stop OC pills and restart after one month


A 30-year-old woman has been using oral contraceptive pillls, combination type for past 8 yrs. However, she also has a history of migraines. Lately, she has been experiencing an average of 14 episodes of severe migraine without aura yearly. Careful evaluation of her headache calender reveals that most of them occur exclusively during the pill-free week of her OC regimen. She has no history of smoking. She has never had DVT or family hx of thrombophilia. Her physical exam is normal without any neurological deficits. Next step in management ?
A. Switch to low dose estrogen pills
B. Switch to minipill
C. Discontinue OC pills
D. Start extended duration OC pills like seasonale

A.....B.....B.....D…



These bites imp stuff are from infectious disease lectures.

1. Do not routinely treat all bites with antibiotics. Only high grade bites need antibiotic prophylaxis. Dirtiest bites are Cat and Human bites.

- In case of cat and dog bites, no necessity for giving prophylactic antibiotics if it is a low grade non-infected bite. Cleansing with sterile/ tap water and debridement are sufficient.

- However, remember that cat bite that is a true puncture wound will need antibiotic prophylaxis as even when they are small they can cause a deep puncture and carry 50% risk of infection. So, if it is a minor scrape or nip , there is no necessity for antibiotics but if there is a puncture, antibiotic should be given. ( Dog bites have less risk of infection)

- If it is a high grade non infected wound, antibiotic prophylaxis should be given to prevent cellulitis ( i.e; if the wound involves the hands, feet, cartilaginous structures, or is deeper than the epidermal layer(puncture).

- Human bites have the highest risk of getting infected. However, antibiotic prophylaxis is recommended only in high grade wounds.

Summary :

Risk of wound infection:
2-30% in dog bites
15-50% in cat bites ( since cat bites are more likely to be puncture wounds, risk of infection is high)
9-50% of human bites

Risk of infection is particularly high in ( high grade wounds): SUCH BITES NEED Antiobiotic prophylaxis
- puncture wounds
- hand injuries
- full-thickness wounds
- wounds involving joints, tendons, ligaments, or fractures.

Treatment of Bite cellulitis ( INFECTED BITES) :

A. CAT - AUGMENTIN, If PCN allergy, use TMP/SMX
B. DOG - AUGMENTIN
C. Human - AUGMENTIN OR AMPI/SULBACTAM. If PCN allergy, use TMP/SMX + Clinda.

Read on bite treatment in PCN allergy, that is very important







Primary closure with sutures :-

not recommended for non-facial bite wounds, deep punctures, bites to the hand, clinically infected wounds and wounds greater than 6 hours old 9 due to high risk of infection) . Delayed closure is appropriate in this conditions.

Facial wounds may need sutures to prevent scarring and improve cosmetic outcome. owever, the risk of such closure is uncertain, but in most cases this is safe if the person has presented early and the wound has been thoroughly cleaned.


Delayed primary closure (after 3-5 days) : -
Recommended for bites to the hand, bites with extensive crush injury, wounds needing a considerable amount of debridement, and wounds more than 6 hours old.
for vaccinated dog bit we do not give antibiotics unless the dog bite on face

yes very low risk with dog bite ...see above : - In case of cat and dog bites, no necessity for giving prophylactic antibiotics if it is a low grade non-infected bite. Cleansing with sterile/ tap water and debridement are sufficient

human, hiv+ bite ?

Q86) A patient had a closed fist injury at a bar while trying to punch his friend who he later learnt was HIV positive. The patient tells you that there was only an abrasion on his hand and all he noted on his hand was his friend’s saliva. He is very concerned. What is your next step?
A. Give HIV prophylaxis with HAART
B. Clean and debride the wound and reassure that no need for prophylaxis
C. Call surgical consult
D. Close the wound with sutures
E. Check for HIV antibodyAnswer is B



- HIV transmission has been reported only very rarely after a human bite.
- Exposure to saliva alone is not regarded as a risk factor for transmission of HIV (or hepatitis). So, CDC does not recommend routine prophylaxis in human bites.

- Transmission risk in human bites is significant when :
If the biter has HIV, his saliva is mixed with his blood and the bite caused a breach in the skin of the victim.
If the Victim has HIV, the blood drawn from him should come in to contact with mucous membranes of the biter ( Victim to biter transmission) .

- CDC (2005) recommends postexposure prophylaxis with active antiretroviral therapy (HAART) ( 28 day course) ONLY in either of the above two scenarios


the surveillance colonoscopy after polyp removal should be based on the risk.
It gives classification of risk as

a) Low Risk: - 1 to 2 adenomatous polyps, both small < 1cm
In this low risk, repeat colonoscopy in 5 years . If this is normal, repeat every 10yrs
( remember 5,10)

b) Intermediate Risk : 3 to 10 small adenomatous polyps or
any one adenomatous polyp >1cm or any adenoma with villous features or high grade dysplasia
In this group, repeat Colonoscopy in 3 years. If this is normal or shows only small polyps, repeat colonoscopy every 5 years ( remember 3, 5)

c) High risk:
- Greater than or equal to 10 adenomatous polyps, colonoscopy at 1 year.
- Sessile adenomatous ployp that are removed in pieces --> colonoscopy in 3 to 6 months to ensure that it is completely removed
- Polyp removed in total and has carcinoma insitu with clear margins --> colonoscopy at 1 year and then at 3 years and then, every 5 years ( Remember 1,3 and 5)

any one adenomatous polyp >1cm you should repeat in 3 years


A 65 y-old male undergoes a screening colonoscopy which reveals a 2cm polyp. The histopathology reveals an adenomatous polyp with no atypical cells. The most appropriate follow up for this patient is :
A) Colonoscopy at 10 yrs
B) Colonoscopy at 5 yrs and then every 5 yrs
C) Colonoscopy at 3 yrs and then every 10 yrs
D) Colonscopy at 3 yrs and then every 5 years
E) CEA every 3 months

Ans. D
The polyp is adenomatous and is large > 1cm ( intermediate risk).




Medicine Question 61

65 Y/O comes with cough and exertional sob of several month duration. He has smoked for 35 years. On physical examination, he is sweating, ruddy, and cyanotic. His pulse rate is120/min and regular, respiration rate is 30/min and labored, and blood pressure is 150/90 mm Hg. The neck veins are distended to the angle of the jaw when sitting upright. The chest shows hyperinflation, prolonged expiration, wheezing, and crackles at each posterior base. The pulmonic sound is increased, and there is a summation gallop. An enlargedand tender liver edge is felt 2 cm below the costal margin. He has marked dependent edema up to the knees.The hematocrit is 55%, and leukocyte count is 8000/μL. Arterial blood gases with the patient breathing room air arePaO2, 47 mm Hg; PaCO2, 50 mm Hg; and pH, 7.30. Spirometry performed 2 years earlier showed a forced expiratoryvolume in 1 sec (FEV1) of 0.65 L and a forced vital capacity (FVC) of 3.05 L. Chest radiography shows hyperinflation, clear lung fields, and biventricular enlargement. Ventilation-perfusion lung scanning shows multiple matched fillingdefects that are not segmental. Doppler studies of the legs are negative.After treatment of the patient’s acute condition, which of the following is the best long-term therapy for
this patient?
( A ) Nifedipine
( B ) Warfarin
( C ) Bosentan
( D ) Oxygen
( E ) Phlebotomy

I THINK IT IS D


MEDICINE 66

Q87) A 42 year old african-american man is admitted to hospital with acute seizures. Seizures were appropriately controlled in the ER and the patient currently, in post-ictal confusion. He is unable to give further history. However, a review of the old records reveal that the patient has history significant of Chronic HIV infection. He also has a history of IV drug use. As per his sister, the patient has been compliant with Highly active anti-retroviral therapy and prophylactic medications for Pneumocystis jiroveci and Mycobacterium Avium Complex for the past one year. His recent CD4 count 1 month ago was 45. On physical examination, he is afebrile with a blood pressure of 120/60. He is confused. Reflexes are intact. Electrolytes and CBC are with in normal limits. Urine drug screen is negative. A non-contrast CT scan did not not reveal any bleed. A CT scan with IV contrast reveals a 4 cm ring – enhancing lesion in left cerberal hemisphere. A subsequent MRI brain confirmed the findings on the CT. There is no mass effect. Next step in approaching this patient ?

A. Stereotactic Brain Biopsy
B. Start emperic Toxoplasma therapy.
C. Obtain Toxoplasma Serology ( IgM and IgG)
D. PCR for Papova Virus JC
E. Emperic therapy for CNS tuberculosis

THINK A
MEDICINE 78

Q96) A 65 year old man with history of DM type II presents to your office with complaints of chest pain that he has been having lately. He denies any pain now. He says his chest pain is more left sided and about 5/10 in intensity and it appears after walking about 2 blocks. The pain disappears after resting for a while. He has been having these chest pain episodes for the past 3 months. He also reports severe crampy leg pain that occurs in his both legs which is also relieved by rest. He denies any shortness of breath. He has smoked about 1 pack per day for the past 40 years. He denies any cough. His only medications are Glyburide and Metformin. An EKG is obtained in the office and it reveals non-specific ST segment changes. Next important step in managing this patient:
A) CT angiogram of Chest
B) Exercise Treadmill Stress test
C) Obtain Cardiac Enzymes
D) Dipyridamole Stress test
E) Start Calcium Channel Blocker

history of smoking but the q does not mention COPD
so D is correct

that is the point of the questions, to create confusion and to give correct concepts.
Dr.Red succeeds very well with tricky concepts. Listen to his cardio lecture, it is very clear on the definitions.

A waxing and waning chest pain for many months, chest pain that appears only on exertion and relieved by REST and the chest pain not present now, why would you look for MI? It is clinically STABLE ANGINA.

" He denies any pain now" is clearly given in the question.

Just because one smokes it is not contraindication for dipyridamole stress test. Presence of symptomatic COPD is the contraindication. The patient has no SOB. Check Dr.Red lecture or slides and also check AHA and ACP guidelines.



MEDICINE 79
102) A 65 year old man presents to your office with increasing abdominal distension and bilateral leg swelling. He reports his symptoms started 3 months ago and progressively worsening. He smokes about one pack cigarettes per day and drinks one pint vodka every day. His last drink was 1 day ago. On examination, he is afebrile and he has abdominal distension and ascites with out any tenderness on palpation. Lab studies show WBC 8k/µl, Hemoglobin of 10.2 gm%, Platelets 90k/µl, Total protein of 6.4, Albumin 2.2, SGOT 300, SGPT 130, Total Bilirubin 4.2 , Direct Bilirubin 3.3, Prothrombin time of 19 seconds and Creatinine 2.2. The patient undergoes diagnostic paracentesis which reveals a total protein of 1.4, albumin of 0.6, WBC count of 400 with polymorphonuclear neutrophils of 100cells/ml. Bacterial cultures are pending. The most important step in managing this patient is :
A) Intravenos Ceftriaxone
B) Intravenos Corticosteroids
C) Intravenos Albumin Infusion
D) Trans-jugular Intrahepatic Porto-systemic Shunt (TIPS)
E) Arrange for Liver Tranplant

103) The most important factor that should be considered in determining the etiology of this patient’s Ascites:
A) Fluid WBC
B) Fluid Albumin
C) Fluid Total protein
D) Serum – Ascites- Albumin – Gradient
E) Serum Albumin and Prothrombin time

I think it is B and D using Discriminant function

MEDICINE 76

Q98) A 68 year old man with history of DM type II, Hypertension and severe osteoarthritis presents to your office with complaints of chest pain on exertion for past 3 months. He denies any pain now. His only medications are Glyburide, Metprolol, Enalapril and Metformin. An EKG is obtained in the office and it reveals non-specific ST segment changes. While undergoing the test, the patient develops severe chest pain and headache. EKG monitor reveals > 2mm ST depressions in the anterior leads. The technician immediately terminates the dipyridamole infusion. After 2 minutes of cessation of infusion, the patient continues to have chest pain. His blood pressure is 88/68 mm hg. The next step in managing this patient :
A) Order Cardiac enzymes
B) Start Heparin infusion
C) Administer Intravenos Aminophylline
D) Reassure the patient that symptoms will improve in few minutes
E) Urgent Cardiac Catheterization



ANSWER. C.
patient is presenting with adverse effects of Dipyridamole. The first step is to stop the infusion. If symptoms persist even 2 mins after infusion, give IV aminophylline which reverses the effects of dypiridamole


MEDICINE 76
A 65 y/o man with presents to your office with complaints of exertional chest pain for the past 4 weeks. The chest pain is usually left sided, occurs on walking about one block and goes away with rest. He denies any chest pain now. He also reports no change in quality or intensity of his chest pain He also reports having been diagnosed with peripheral arterial disease about 2 months ago for which he was advised exercise therapy. He does experience leg pain on walking about one block which also improves with rest. His past medical history is significant for moderate COPD, Hypertension and a hernia repair about 3 years ago. His medications include lisinopril, hydrochlorthiazide and tiotropium inhaler. Physical examination is benign. The next best step in establishing the diagnosis in this patient is :
A) 2 D -Echocadiogram
B) Exercise Stress Test ( Treadmill Stress Test)
C) Dobutamine Stress Echocardiogram
D) Persantin Stress Test
E) Cardiac Catheterization

ANSWER IS C.
Explanation

This patient presents with symptoms suggestive of ischemic heart disease. So, needs a stress test to establish the diagnosis.
Exercise Stress test is a tachycardic stress test. He cannot walk to reach his maximum heart rate secondary to peripheral arterial disease and this will limit the exercise test. So, exercise stress test can not be done.
He has moderate COPD. Using persantin in patients with COPD/ asthma can exacerbate bronchospasm .
The preferred choice in this patient is, therefore, Dobutamine Stress Echo
*****heart block is another contraindication for persantin stress test


MEDICINE 77
Q97) A 68 year old man with history of DM type II, Hypertension and severe osteoarthritis presents to your office with complaints of chest pain on exertion for past 3 months. He denies any pain now. He smokes about one pack cigarettes per day. His only medications are Glyburide, Metprolol, Enalapril and Metformin. An EKG is obtained in the office and it reveals non-specific ST segment changes. The patient is scheduled for Dipyridamole stress test . The patient should be advised regarding which of the following:
A) Avoid Aspirin or NSAID for 24 hours prior to testing
B) Stop Metprolol 24 hours prior to tesing
C) Avoid Coffee or Caffeine for 24 hours prior to testing
D) Avoid smoking for one week prior to testing
E) Start inhaled Albuterol two days prior to testing

ANSWER IS C
xanthine derivatives such as caffeine may abolish the coronary vasodilatation induced by intravenous dipyridamole administration. This could lead to a false negative result . Xanthine derivatives should be avoided 24 hours before myocardial imaging with IV dipyridamole

B is the big issue with exercise stress test.

But C is choice for persatin and adenosine stress tests.
Q95). A 62 year old man with history of DM Type II and Coronary Artery Disease presents to the Emergency room with right leg pain and swelling. The pain and swelling started 2 days ago and has been increasing. He denies any fever, chest pain or shortness of breath. He was recently admitted to the hospital 10 days ago for Non ST elevation Myocardial infarction. The patient was treated at that time with medical management that included Heparin, Clopidogrel, Aspirin and Beta blockers. The patient was discharged with instructions to continue aspirin, clopidogrel and metoprolol. At the time of discharge. his labs were all with in normal limits. He says he has an appointment with his cardiologist’s office next week for further work-up. He denies any bleeding. Physical examination reveals ankle tenderness and mild swelling of the right lower extremity up until his mid thigh. Laboratory investigations reveal a WBC of 5100, HGB 14.2 and a platelet count of 40k/µl ( N = 160 to 400k/µl. Prothrombin time and partial thromboplastin time with in normal limits. A venos doppler reveals a common femoral to popliteal DVT in his right lower extremity. Next step in managing this patient ?

A) Start Low Molecular Weight Heparin

B) Start Warfarin

C) Place Inferior Vena Cava Filter due to bleeding risk

D) Start Lepirudin

E) Platelet Transfusion

B. Which of the following is most likely to establish the diagnosis in this patient?

A) Lupus Anticoagulant Profile

B) Anti Platelet Factor 4/ Heparin antibodies

C) Factor V leiden mutation

D) Prothrombin gene mutation

E) Peripheral Blood Smear

ANWERS ARE B, D
this is the case of HIT syndrome, probably caused by heparin during his previous admission for MI,

if patient continue to have DVT then IVC filter.

Q64) A 44 year old man presents to your office with pain and swelling of the small joints in his hands and wrists. The symptoms have been progressing over the past 4 months. He denies any fever or weightloss. He reports stiffness in his both hands that occurs every morning and lasts for 2 hours. On examination, he has symmetrical involvement of both wrists and proximal interphalangeal joints. The involved joints are swollen and tender. Laboratory tests shows high ESR, negative rheumatoid factor, and a positive anti-CCP antibody. X-ray of the wrist and hands reveal erosions in the proximal phalanges and ulnar styloid process. The most appropriate next step in management :

A. Prednisone
B. Start NSAID and follow-up in one month.
C. Start NSAID and Methotrexate
D. Start Infliximab
E. Start NSAID and Hydroxychloroquine

Ans. C
This patient has severe rheumatoid arthritis. He has all the criteria for the diagnosis of RA ( morning stiffness greater than 1hr, symmetricity, hand joint involvement, more than 3 joints, +ve CCP and bony erosions). His disease can be classified as "severe" because he has high ESR, high CCP and most importantly, he has erosive bony disease.

Therapy depends on severity at the time of diagnosis ( in early RA) :-
Mild RA : NSAID alone can be started first. NSAID does not prevent disease progression or erosive bone disease. If symptoms persist or progress while on NSAIDS or if no remission occurs after six weeks on NSAID therapy, a disease modifying agent must be added ( DMARD). For mild disease, a less toxic DMARD such as Hydroxychloroquine or Sulfasalazine must be used initially ( not methotrexate).

Moderate RA : NSAID + less toxic DMARD such as hydroxychloroquine should be started from the time of diagnosis.

Severe RA : An NSAID along with a more potent DMARD such as Methotrexate should be started together as initial therapy. NSAID alone should not be used as sole therapy in severe RA as it will not prevent disease progression. In patients who can not be started on MTX ( for contraindications), a TNF alpha inhibitor such as leflunomide or etanercept must be started as initial DMARD.

Ans. A is incorrect. Prednisone is usually used for treating RA flares.

Ans. B is incorrect. This option is appropriate if the patient is determined to have early, mild RA. Patients can be started on NSAID alone and follow up in 1 month to see if there is remision. If disease is still present, DMARD must be added.

Ans. D is incorrect. This option is correct if the patient is determined to have early, severe RA and if the patient can not be started on DMARD such as methotrexate

Ans. E is incorrect. This option is appropriate if the patient is determined to have early, mild RA or moderate RA. Patients can be started on NSAID alone in mild RA and follow up in 1 month to see if there is remision. If THE disease is still present, a mildly toxic DMARD must be added
such as hydroxychloroquine or sulfasalazine.
Besides, these are the criteria for RA:

The American College of Rheumatology has defined the following criteria for the classification of rheumatoid arthritis:

-Morning stiffness of greater than 1 hour most mornings for at least 6 weeks.
-Arthritis and soft-tissue swelling of greater than 3 of 14 joints/joint groups, present for at least 6 weeks.
-Arthritis of hand joints, present for at least 6 weeks
-Symmetric arthritis, present for at least 6 weeks
-Subcutaneous nodules in specific places
-Rheumatoid factor at a level above the 95th percentile
-Radiological changes suggestive of joint erosion

You need four of these.
44 year old woman presents to your office with pain and swelling of the small joints in his hands and wrists. The symptoms have been progressing over the past 4 months. She denies any fever or weightloss. She reports stiffness in his both hands that occurs every morning and lasts for 2 hours. On examination, she has symmetrical involvement of both the wrists and two of her left proximal interphalangeal joints. The involved joints are swollen and tender. Laboratory tests shows normal ESR, negative rheumatoid factor, and a negative anti-CCP antibody. X-ray of the wrist and hands reveal mild joint space narrowing with only very small peripheral erosions. The most appropriate next step in management :

A. Prednisone
B. Start NSAID and follow-up in one month.
C. Start NSAID and Methotrexate
D. Start Infliximab
E. Start NSAID and Hydroxychloroquine

The patient in the above question is started on appropriate therapy. He returns to your clinic in 1 month for regular follow up and his disease is well controlled with near complete remission. The most important next step in follow up of this patient :

A. DEXA scan in 1 year
B. PPD placement
C. Check hepatitis B serology
D. Ophthalmology referral at 3 months
E. Liver function tests

ANSWER E, D

A 65 y/o man with presents to your office with complaints of exertional chest pain for the past 4 weeks. The chest pain is usually left sided, occurs on walking about one block and goes away with rest. He denies any chest pain now. He also reports no change in quality or intensity of his chest pain He also reports having been diagnosed with peripheral arterial disease about 2 months ago for which he was advised exercise therapy. He does experience leg pain on walking about one block which also improves with rest. His past medical history is significant for moderate COPD, Hypertension and a hernia repair about 3 years ago. His medications include lisinopril, hydrochlorthiazide and tiotropium inhaler. Physical examination is benign. The next best step in establishing the diagnosis in this patient is :
A) 2 D -Echocadiogram
B) Exercise Stress Test ( Treadmill Stress Test)
C) Dobutamine Stress Echocardiogram
D) Persantin Stress Test
E) Cardiac Catheterization

ANSWER IS C.
Explanation

This patient presents with symptoms suggestive of ischemic heart disease. So, needs a stress test to establish the diagnosis.
Exercise Stress test is a tachycardic stress test. He cannot walk to reach his maximum heart rate secondary to peripheral arterial disease and this will limit the exercise test. So, exercise stress test can not be done.
He has moderate COPD. Using persantin in patients with COPD/ asthma can exacerbate bronchospasm .
The preferred choice in this patient is, therefore, Dobutamine Stress Echo

heart block is another contraindication for persantin stress test,

Q98) A 68 year old man with history of DM type II, Hypertension and severe osteoarthritis presents to your office with complaints of chest pain on exertion for past 3 months. He denies any pain now. His only medications are Glyburide, Metprolol, Enalapril and Metformin. An EKG is obtained in the office and it reveals non-specific ST segment changes. While undergoing the test, the patient develops severe chest pain and headache. EKG monitor reveals > 2mm ST depressions in the anterior leads. The technician immediately terminates the dipyridamole infusion. After 2 minutes of cessation of infusion, the patient continues to have chest pain. His blood pressure is 88/68 mm hg. The next step in managing this patient :

A) Order Cardiac enzymes

B) Start Heparin infusion

C) Administer Intravenos Aminophylline

D) Reassure the patient that symptoms will improve in few minutes

E) Urgent Cardiac Catheterization

ANSWER. C.
patient is presenting with adverse effects of Dipyridamole. The first step is to stop the infusion. If symptoms persist even 2 mins after infusion, give IV aminophylline which reverses the effects of dypiridamole .
Q97) A 68 year old man with history of DM type II, Hypertension and severe osteoarthritis presents to your office with complaints of chest pain on exertion for past 3 months. He denies any pain now. He smokes about one pack cigarettes per day. His only medications are Glyburide, Metprolol, Enalapril and Metformin. An EKG is obtained in the office and it reveals non-specific ST segment changes. The patient is scheduled for Dipyridamole stress test . The patient should be advised regarding which of the following:

A) Avoid Aspirin or NSAID for 24 hours prior to testing

B) Stop Metprolol 24 hours prior to tesing

C) Avoid Coffee or Caffeine for 24 hours prior to testing

D) Avoid smoking for one week prior to testing

E) Start inhaled Albuterol two days prior to testing

Ans. C
one of the contraindications FOR DIPYRIDAMOLE STRESS is consumption of coffee or caffeine in the prior 24 hours as it can cause false -ve test

Correct Ans C

Stop caffeine intake

The coronary vasodilatory effect of dipyridamole is competitively blocked by caffeine..

DIPYRIDAMOLE TEST

Dipyridamole augments endogenous adenosine, causing coronary artery
vasodilation. It increases myocardial blood flow in normal coronary arteries but not in arteries distal to a stenosis, creating a “steal” phenomenon from stenosed arteries and an imbalance in perfusion. Dipyridamole -induced ischemia or other adverse effects (eg,nausea, vomiting, headache, bronchospasm) occur in about 10% of patients, but these effects can be reversed by IV aminophylline. Severe reactions occur in < 1% of patients. Contraindications include asthma, acute phase MI, unstable angina pectoris, critical aortic stenosis, and systemic hypotension (systolic BP < 90 mm Hg.



Q122) A 75 year old man presents to your office with complaints of severe fatigue and constipation for the past one week. He has no significant past medical history except for benign prostatic hypertrophy for which he takes terazosin. Physical examination reveals mild tenderness in left mid thigh area. Rest of the exam is normal. An x-ray of the left lower extremity reveals a lytic lesion in the shaft of the femur. A subsequent bone scan reveals multiple lytic lesions in the ribs, right iliac bone, left and right femur shaft as well as in the left femur neck. The most important next step in managing this patient’s symptoms is :

A) Serum PSA level
B) Serum protein electrophoresis
C) Start IV Bisphosphonates
D) Check serum calcium level and start IV hydration
E) Skeletal survey

Q123) The patient was admitted to the hospital and his symptoms were managed appropriately. However, during the second hospital day the patient complains of pain in his left thigh. Review of his previous x-ray reveals lytic lesion occupying the head and neck of femur. The most important immediate next step in managing this condition

A) MRI of the Hip
B) CT scan of the Hip
C) Orthopedic consultation for internal fixation
D) Radiation therapy
E) Chemotherapy



The answers are D and B

METASTATIC CANCER/ OSTEOLYTIC METS PRESENTING WITH SYMPTOMS OF HYPERCALCEMIA - abdominal symptoms, fatigue. Firstr step is D - check ca, iv hydration and then IV bisphosphonates

Q2 is B. most important here is to recognize the danger of impending fracture in the long bones from the mets. If the lytic lesion is involving more than 2/3 of cortical bone, it can fracture...so needs intramedullary nail placement by ortho. Before doing anything, CT scan should be done to assess the bone if the lesion is occupying that much area and see if there is underlying fracture. CT SCAN better than MRI because ct is good for bones but mri is not. MRI is good for soft tissues

QUES 9
A 65 y/o man with history of chronic smoking and COPD presents for follow up visit in your office after being discharged from the hospital about three weeks ago. The patient was admitted and treated in the hospital for community acquired pneumonia and COPD exacerbation. During his hospital stay he was noted to have microscopic hematuria on routine urinalysis. The patient denies any symptoms now. His COPD is well controlled on tiotropium inhaler. His allergies include Isoniazid and Penicillin. Past medical history is significant for a positive PPD test ( latent tuberculosis) for which he has been on treatment with Rifampin for past three months. Physical examination is benign. Labarotory investigations reveal a normal CBC and serum creatinine. Dipstick is positive for blood. A repeat urinalysis during this visit reveals persistent microscopic hematuria with 3 RBCs/HPF. A urine cytology has been ordered. The next appropriate step in evaluating this patient’s hematuria is:
A) Repeat urinalysis in 3 months
B) Non-Contrast CT scan
C) Intravenos pyelogram
D) CT urogram + Cystoscopy
E) Stop Rifampin

Ans. D
This patient has significant microhematuria defines as 3 0r more RBCs/HPF established on two occassions. He also has high risk factors for having a bladder cancer or urological malignancy. So, both upper tract imaging in the form of CT urogram as well as bladder visualization in the form of cystoscopy are warranted in this patient.
A. is incorrect because the patient already had >3RBCs/HPF on two occassions already establishing the diagnosis of significant microhematuria.
B. is incorrect because this patients has no symptoms or lab findings suggesting UTI.
C. is incorrect because this patient is a high risk patient and requires both upper tract imaging as well as cystoscopy as an initial protocol. IVP is good for upper urinary tract imaging but does not adequately visualize the bladder. More over, recent recommendations favor CT urogram over IVP for upper tract imaging.
E. is incorrect. Rifampin causes red colored urine but does not cause positive dipstick or hematuria





Q10
A 55 y/o man presents with shortness of breath on exertion. Laboratory studies reveal iron deficiency anemia. Patient was started on Iron pills orally. The patient consumes a lot of red meat and was surprised to know that he was iron deficient. Fecal occult blood testing revealed a positive stool guaic. A colonoscopy and EGD were subsequently performed which were absolutely normal. A repeat Guaic was performed and was found to be negative. A further investigation for the cause of iron deficiency in this patient revealed celiac disease leading to iron malabsorption. What is the most likely cause of positive Guaic in this patient? •
A. Obscure GI Bleeding
B. Celiac disease
C. False positive from red meat
D. False positive from Iron pills
E. Colon cancer

Ans. C
Red meat can lead to false positive guaic as it may oxidize the guaic reagent ( Vitamin C on the other hand, anti-oxidizes it and causes false –ve guaic.)
Obscure bleeding ( Ans. A) is possible but in this patient the most likely cause for iron deficiency was already established as celiac disease making intermittent obscure bleeding less likely.
Celiac disease ( Ans. B) does not cause False +ve Guaic.
Iron pills ( Ans. D) can cause black discoloration of the stool but not a false positive guaic.
The fact that the colonoscopy was normal makes bleeding from colon cancer ( Ans. E) unlikely here







Q12) A 12 y/o boy is brought to you by his mother for skin rash and complaints of intermittent abdominal pain, joint pains for past 2 days. He did have an upper respiratory infection about 2 days ago. On physical exam, his vitals are normal. Abdomen is benign with out any tenderness or rigidity. However, you notice patchy purple discolorations on his extremities and the back. Lab studies are obtained that revealed

WBC: 6.6 , HGB: 15.3 , MCV: 88 , Platelets: 290,000 ( normal 180k to 400k)
BUN: 11 , Creatinine : 0.6 ( normal) , Anti streptolysin O titer : negative
Streptozyme : negative ,Urine dipstick : normal without any blood
Urinalysis : normal/ no rbcs/ no protein
The mother is very anxious and asks about the long term prognosis of her son. Your response :
A) Reassure the mother that boys disorder is self limiting and does not require any follow up
B) Tell her the boy needs to be admitted and treated vigorously to prevent renal failure
C) Tell her that renal failure develops 100% of such cases and hence needs very cautious follow up
D) Tell her that 50% of such cases progress to end stage renal disease.
E) Tell her that the boy requires follow up monthly urinalysis for at least 3 months in order to make sure there is no heamaturia/ renal dysfunction.
Q13) If the boy presented with Renal failure in the above case, the most likely underlying pathology would be :
A) IgA mediated vasculitis
B) Post streptococcal glomerulonephritis
C) Anti GBM disease
D) Acute tubular necrosis
E) Interstitial Nephritis.

Answers :
Q12) E
Q13) A
Q12, E) Tell her that the boy requires follow up monthly urinalysis for at least 3 months in order to make sure there is no heamaturia/ renal dysfunction – is the correct answer.
The patient has non thrombocytopenic purpura associated with abdominal pain and arthralgias. These features are consistent with the diagnosis of Henoch Schonlein Purpura
( HSP). The initial episode of HSP usually resolves within one month. Renal impairment may be seen at the first presentation. However, some children may manifest with late renal disease. In children with no renal impairment at presentation, Urinalysis and blood pressure monitoring should be followed monthly for three months after presentation. In children presenting with renal involvement at the first presentation, should be followed more carefully i.e; urinalysis every week for first 2 months and then every month for one year. Patients with persistent proteinuria, hypertension, or renal insufficiency should be referred to nephrology for further evaluation and treatment.
Choice A is incorrect because though the disease is self limiting, it needs to be followed for possible development of renal impairment.
Choice B is incorrect – no admission required because the boy has an initial mild attack of HSP with out any renal impairment at this time.
Choice C is incorrect because renal impairment may be seen only in about 20 to 50% cases of HSP. Renal involvement is typically seen with in one month of onset of systemic symptoms.

Choice D is incorrect because only 2 to 5% patients progress to End Stage Renal Disease.

Q13) A
HSP is IGA mediated vasculitis. IgA nephropathy and Henoch-Schoenlein purpura are two different entities that can lead to renal disease. The mechanism of renal disease in HSP is a vasculitis that is mediated by IgA. Extrarenal manifestations are seen most often in patients with Henoch-Schoenlein purpura where as they are uncommon in IgA nephropathy. HSP associated renal disease tends to be self-limiting in majority of cases where as IgA nephropathy is often associated with persistent or recurrent hematuria and/ or proteinuria

A 76 year old debilitated man with history of advanced dementia lives in an extended care facility. He has a history of recurrent Urinary tract infections which develop every six months with mild fever, frequency of micturition and urinary incontinence. In the past, his urine cultures revealed E.coli > 100,000 colonies on several occassions. He has no indwelling Foley catheter and he is only placed on diapers. His vital signs are temperature of 98.6, HR 88, RR 18 and a BP of 130/84. A nurse practioneer has routinely ordered a urinalysis which revealed positive leucoesterase and nitrite. This was followed by a urine culture that revealed 100,000 colonies of E.coli. The nurse is concerned about this finding and calls you for appropriate management.
What is the appropriate treatment?

A. Cystoscopy and Intra-venos pyelogram
B. Continuous low dose antibiotics for prevention of recurrent UTIs
C. Catheterize and irrigate the Bladder daily
D. Intravenos antibiotics with broad spectrum coverage
E. No need of treatment as this is colonization

Ans. E.

Key Concepts : Recognize the definition of "Recurrent" UTI . Recognize the difference between "colonization" and "Active Infection"

Answer. E No need of treatment is the correct choice because this old man has no signs of active infection at this time. He has no fever or tachycardia or any signs of sepsis or infection.

Ans. A is incorrect. Cystoscopy and IVP can be performed to evaluate the urinary tract if the patient had severe UTI or recurrent UTI. It is not the appropriate step at this time.

Ans. B would be appropriate as a prophylactic therapy if the patient has Recurrent UTI. Understand that the Recurrent UTI is defined as 2 or more episodes in past 6 months or 3 or more episodes in past one year. This patient does not meet the criteria of recurrent UTI since he suffers only one episode every 6 months.

Ans. C is not helpful in preventing UTI and is also, not appropriate step at this time. Indwelling catheters may in fact, increase the risk of UTIs.

Ans. D would be appropriate if the patient had severe UTI. He has no signs of acute infection at this
 
Report Abuse

 
 

* Re:collection of previously posted questions
#2385334
  forever07 - 04/28/11 13:22
 
  Very good one, let me ask you are these Q are Archer's blog?  
Report Abuse

* Re:collection of previously posted questions
#2385709
  yvyhope - 04/28/11 22:23
 
  greatpost!!  
Report Abuse

* Re:collection of previously posted questions
#2408443
  misshyd - 06/06/11 18:47
 
  UP

Questions from Archer review with answers, thanks for collecting usmle1
 
Report Abuse

* Re:collection of previously posted questions
#2433036
  misshyd - 07/18/11 21:45
 
  this is a nice collection of some Archer questions with explanations, up  
Report Abuse

* Re:collection of previously posted questions
#2449829
  misshyd - 08/14/11 19:39
 
  collection of explanations  
Report Abuse

* Re:collection of previously posted questions
#2481196
  misshyd - 09/21/11 22:07
 
  up for previous questions seekers  
Report Abuse

* Re:collection of previously posted questions
#2513852
  kinsley - 10/31/11 00:43
 
  ''  
Report Abuse

* Re:collection of previously posted questions
#2525507
  zamora - 11/16/11 20:25
 
  thanks amigos  
Report Abuse

* Re:collection of previously posted questions
#2591295
  senor - 02/17/12 17:41
 
  thanks are all answers confirmed correct??  
Report Abuse

          Page 1 of 1          

[<<First]   [<Prev]  ... Message ...  [Next >]   [Last >>]

 
Logon to post a new Message/Reply
 
 
 
 

 

 

Google
  Web USMLEforum.com
 

Step 1 Step 2 CK Step 2 CS Matching & Residency Step 3 Classifieds
LoginUSMLE LinksHome