12-19-2008, 12:33 AM
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1. A 23-year-old registered nurse comes to the employee health clinic because she says, "I'm too tired to work." She has had increasing fatigue, malaise and anorexia during the past several days. Her serum bilirubin concentration is 1.8 mg/dL, prothrombin time is 13 sec, serum alanine aminotransferase (ALT) concentration is 1160 U/L and a screening test for hepatitis B surface antigen is positive. She is instructed to rest at home and return in 3 days if no new symptoms develop. Two days after the visit she calls to say that she has now developeed an urticarial rash and swelling of the joints of her fingers. At this time the most correct statement about her condition is:
a) The arthritis and rash are the result of an associated immune complex disorder
b) The arthritis and rash are unrelated to her liver disease
c) It is unlikely that her blood is infectious
d) She has a 50% risk for developing chronic liver disease
e) She should be given hepatitis B immune globulin
View Answer A: Associated autoimmune complex disorder
Chronic active hepatitis of unknown etiology ("auto-immune" or "lupoid" chronic hepatitis)
This classic form of chronic active hepatitis (CAH) cannot be attributed to any known cause, and the original histologic classification referred to earlier was developed primarily in studies of this entity. First described by Waldenstrom in 1950 and Kunkel in 1951, the disease was thought to occur primarily in young women and demonstrated many autoimmune characteristics, including a positive lupus erythematosus (LE) cell phenomenon. It is now recognized that the disease occurs in persons of all ages and both sexes. Endocrine abnormalities (amenorrhea, hirsutism, acne, obesity, cushingoid facies, pigmented abdominal striae) and the LE cell phenomenon occur in only a small minority of patients and correlate with severity of disease rather than indentifying a unique subgroup. In contrast to chronic hepatitis B, which typically affects men, 70% to 80% of the patients are women. In one third of patients, the initial disease is identical to acute viral hepatitis. The remainder present insidiously with nonspecific symptoms of malaise, fatigue, and anorexia; are identified serendipitously on a random serum chemistry drawn for other reasons; or present with fully developed complications of advanced liver disease (ascites, variceal bleeding, hepatic encephalopathy). At least 85% of the patients have no history of exposure to jaundiced persons or other hepatitis risk factors.
Common clinical features on presentation include progressive jaundice, severe anorexia, malaise and fatigue, asymptomatic hepatosplenomegaly, and abdominal pain. Less common (20% or less) are epistaxis, acne, persistent fever, and tender hepatomegaly. Extrahepatic manifestations may occur in 20% to 25% of patients, with arthralgias and skin rashes the most common. Other abnormalities include thyroiditis, ulcerative colitis, pleurisy, pericarditis, myocarditis, and pulmonary complications, including fibrosing alveolitis. Isolated occurrences of lichen planus, mixed connective tissue disease, macroglobulinemia, and uveitis have been recorded. The multitude of disparate findings further support the likelihood of an immune origin for this disease, but it should be noted that some of these immune abnormalities (skin rashes, glomerulonephritis, arthritis) can be found in chronic hepatitis B due to immune complex desposition.
HBsAg-The appearance of HBsAg is the first evidence of HBV infection, appearing before biochemical evidence of liver disease. HBsAg persists throughout the clinical illness. Persistence of HBsAg after the acute illness may be associated with clinical and laboratory evidence of chronic hepatitis for variable periods of time. The detection of HBsAg establishes infection with HBV and implies infectivity.
HBV is usually transmitted by inoculation of infected blood or blood products or by sexual contact and is present in saliva, semen, and vaginal secretions.
Related topics:
Chronic active hepatitis C
Up to 60% of patients with post-transfusion hepatitis C develop chronic liver disease. Most often, the patient is only mildly symptomatic and nonicteric. Transaminases range from 200 to 800 and may show marked fluctuations, with rapid rises and falls and intervening periods of normality. Although post-transfusion hepatitis C affects men and women equally, 75% of those developing chronic hepatitis in one study were men. Similar to chronic hepatitis B, serum autoantibodies, hypergammaglobulinemia, and stigmata of chronic liver disease are rare, although a false-positive test for antinuclear antibodies may be present in some cases, leading to confusion with autoimmune hepatitis.
No good prospective histologic data are available in this group of patients, but CAH (usually without bridging or cirrhosis) is most common. Although it was initially thought that chronic active hepatitis C was a relatively benign disease, there is increasing evidence of slow progression to cirrhosis and liver failure. At least 20% of patients with CAH progress to cirrhosis within 5 to 10 years. Hepatitis C is the most common cause of cryptogenic cirrhosis and a common reason for liver transplantation in the United States. A strong association with the development of hepatocellular carcinoma is also recognized, with a particularly high correlation in Japan and Spain. Hepatitis A and hepatitis E do not produce CAH or CPH, and hepatitis D produces these lesions only in patients also infected with hepatitis B. In the latter instance, the frequency and severity of chronic hepatitis is greater than with hepatitis B alone.
2. A 19-year old archeology student comes to the student health service complaining of severe diarrhea with fifteen large-volume watery stools per day for the past 2 days. She has had no vomiting, hematochezia, chills or fever, but she is very week and very thirsty. She just returned from a 2-week trip to a remote Central American archeological research site. Physical examination shows temperature 37.2 C (99.0F), pulse 120/min, respirations 12/min and blood pressure 90/50 mm/Hg. Her lips are dry and skin turgor is poor. The most likely cause of the diarrhea is
a) anxiety and stress from traveling
b) inflammatory disease of the large bowel
c) poor eating habits during her trip
d) an osmotic diarrheal process
e) a secretory diarrheal process
View Answer E: Secretory diarrheal process
Increased fecal water content can result from either a decrease in the amount of fluid absorbed or an increase in the secretion of fluid sufficient to overwhelm the absorptive capacity of the bowel distal to the secretory site. Decreased absorption of fluid can occur as a result of (1) inability to absorb osmotically active solutes, which subsequently retain water in the lumen of the gut (Chapter 42); (2) lack of contact between intraluminal contents and absorptive surfaces; (3) change in active ion transport; and (4) increase in tissue hydrostatic pressure.
Osmotic Diarrhea Secretory Diarrhea
Laxatives
Malabsorption
Bacterial Endotoxins
Vasointestinal Peptide
Merck Manual Recommended Reading for Question 2:
DIARRHEA
Etiology and Pathophysiology
Complications of Diarrhea
Diagnosis
Treatment
3. A 64 year old white man comes to the clinic because of chest pain for the past 2 months. He has had intermittent episodes of substernal pain that occur at various times of the day and last 5 to 10 minutes. Physical examination is normal as is an electrocardiogram. The next step in evaluating his symptoms should be to order
a) a chest x-ray film
b) echocardiography
c) an exercise stress test
d) upper gastrointestinal endoscopy
e) 24-hour monitoring of cardiac rhythm
View Answer C: Exercise stress test
The main indication for exercise testing is to assist in the diagnosis of coronary artery disease in patients with chest pain. A second major indication is to evaluate functional capacity and aid in assessing the prognosis of patients with known coronary artery disease. When exercise stress is sufficient to produce a mismatch between myocardial O2 supply and demand, myocardial ischemia will develop and often is identified by certain alterations in the ECG's S-T segment. Although anginal chest pain induced by the test is strongly predictive of coronary artery disease, 1.0 mm of horizontal or downsloping S-T segment depression is considered a positive end-point for ischemia. The S-T depression must persist for 80 milliseconds (ms) or longer and must be recognized in at least three consecutive beats with a steady ECG baseline. Increasing S-T segment elevation can often be seen in leads demonstrating pathologic Q waves at rest in patients with prior myocardial infarction. These changes are predominantly observed in patients with a depressed ejection fraction and severe regional myocardial asynergy.
Quoted from the message group:
Effort testing is the way to go here
by IMG in distress!
Given the patient's symptoms and demographics, the most important thing to exclude would be ischaemic heart disease. In the absence of abnormal clinical features or dysrhythmia, investigations such as echo or CXR would be second line. Thus, to delineate the patient's response to an effort test would be the initial workup. Even in the event of there being an underlying occlusive/stenotic coronary lesion, the stress EKG would only be positive in about 40% of cases (I have heard figures ranging from 30 to 70%). Common questions clinically are (1) what determines a SEKG to be positive, (2) what further investigations one could perform if still suspicious about IHD (plus their rationale and mechanisms) and (3) what to do if the patient is not "stressable" (eg. persantin perfusion study).
Posted on Thursday, March 26, 1998 at 10:51 AM
Merck Manual Recommended Reading for Question 3:
ANGINA PECTORIS;Diagnosis
ANGINA PECTORIS;Differential Diagnosis
4. A 75 year old woman comes to the clinic because she has band-like burning pain in the right upper quadrant extending from the epigastrium around to the midline of the back. On physical examination, there is no abdominal tenderness. Findings on ultrasonography of the gallbladder are normal; serum amylase concentration is normal. The most likely diagnosis is
a) acalculous cholecystitis
b) chronic relapsing pancreatitis
c) diverticulitis of the cecum
d) herpes zoster
e) penetrating duodenal ulcer
View Answer D: Herpes zoster
Herpes Zoster is also known as Shingles
H & P
Prodrome of pain and paresthesia in involved dermatome which may simulate pleu7risy, MI, ulcer, or renal colic. The typical rash is localized, unilateral, and does not cross the midline. Grouped vesicles on a pink base form pustules and crusts.
Diagnosis
Positive Tzank Smear demonstrating multinucleated giant cells, viral culture
This diagnosis is the same as for varicella
Disease Severity
Pain is more severe in elderly patients
disease is more severe in immuocompromised = skin necrosis and scarring, postherapetic neuralgia, dissemination.
Concept and Application
Infection is a recrudescence of latent infection with varicella-zoster infection, passed to the skin and mucosa by sensory nerves from dorsal ganglia
cellular immunity is more important in host resistnace (increased incidence of infection in patients with HIV or immunocompromise)
Management
Topical
Cool compresses
Calamine Lotion
Antibiotics for secondary bacterial infection
Systemic
Acyclovir 800 mg 5 times/d for 1 week
Famciclovir 500 mg 3 times/d, analgesics
Postherpetic Neuralgia
Topical capsaicin cream (Zostrix)
Merck Manual Recommended Reading for Question 4:
HERPES ZOSTER
ACUTE CHOLECYSTITIS
ABDOMINAL PAIN;Diagnosis
THE MERCK MANUAL - PEPTIC ULCER;Diagnosis and Differential Diagnosis
THE MERCK MANUAL - ACUTE PANCREATITIS;Laboratory Findings and
5. An 18 month-old white infant is brought to the clinic because of pallor and irritability. Her mother says the infant's diet consists almost exculsively of whole milk, approximately 40 oz per day. On physical exam, she has a pulse of 160/min, respirations of 50/min, and normal heart sounds with a grade 2/6 systolic ejection murmur. Her liver is palpable 3 cm below the right costal margin. Laboratory studies show:
Hematocrit 13%
Hemoglobin 3 g/dL
MCV 48 um3
Platelets 400,000/mm3
Reticulocyte count 0.8% (N=0.5-1.5% of red cells)
WBC 12,000/mm3
Following other appropriate studies, the most appropriate management would be to
a) administer oral folate therapy
b) administer parenteral iron therapy
c) administer parenteral vitamin B12 (cyanocobalamin) therapy
d) begin transfusion with packed erythrocytes
e) begin transfusion with whole blood
Back to questions 1-5
6. An 18-year-old woman comes to the clinic because she has missed two menstrual periods. She says she has not been sexually active. The pelvic examination is difficult because she is tense and complains of pain throughout the examination. The most appropriate next step is to
a) arrange pelvic ultrasonography
b) do a urine preganancy test
c) determine serum follicle-stimulating hormone (FSH) and luteinizing hormone (LH) concentrations
d) prescribe medroxyprogesterone therapy, 10 mg orally every day for 10 days
e) reassure the patient that this is normal for her age, but she should return in 3 months if her periods do not resume.
View Answer B: Do a urine pregnancy test
7. A 12 year old girl is referred to the clinic by the school nurse for evaluation of scoliosis. Her scoliosis was detected during a routine screening examination at the school and appears mild (curve less than 10 degrees). She is athletic and is otherwise in good health. During the physical examination, particular attention should be given to:
a) arm length
b) blood pressure
c) body weight
d) cardiac examination
e) stage of pubertal development
View Answer E: Stage of pubertal development
The term scoliosis denotes lateral curvature of the spine, which is always associated with some rotation of the involved vertebrae. Scoliosis is classified by its anatomic location, in either the thoracic or lumbar spine, with rare involvement of the cervical spine. The convexity of the curve is designated right or left. Thus, a right thoracic scoliosis would denote a thoracic curve in which the convexity is to the right; this is the most common type of idiopathic curve. Posterior curvature of the spine (kyphosis) is normal in the thoracic area, although excessive curvature may become pathologic. Anterior curvature is called lordosis and is normal in the lumbar and cervical spines. Idiopathic scoliosis generally begins at about 8 or 10 years of age and progresses during growth. In rare instances, infantile scoliosis may be seen in children 2 years of age or less.
Idiopathic scoliosis is about four or five times more common in girls than in boys. The disorder is usually asymptomatic in the adolescent years, but severe curvature may lead to impairment of pulmonary function in later years. It is important to examine the back of any adolescent coming in for a routine physical examination in order to identify scoliosis early. The examination is performed by having the patient bend forward 90 degrees with the hands joined in the midline. An abnormal finding consists of asymmetry of the height of the ribs or paravertebral muscles on one side, indicating rotation of the trunk associated with lateral curvature.
Diseases that may be associated with scoliosis include neurofibromatosis, Marfan's syndrome, cerebral palsy, muscular dystrophy, poliomyelitis, and myelodysplasia. Neurologic examination should be performed in all children with scoliosis to determine whether these disorders are present.
Five to 7% of cases of scoliosis are due to congenital vertebral anomalies such as a hemivertebral or unilateral vertebral bridge. These curves are more rigid than the more common idiopathic curve (see below) and will often increase with growth, especially during adolescence.
Eighty percent of scoliosis is idiopathic. Since 30% of family members are also affected, siblings of an affected child should be examined.
Idiopathic infantile scoliosis, occurring in children 2-4 years of age, is quite uncommon in the United States; it is more common in Great Britain. If the curvature is less than 30 degrees, the prognosis is excellent, as 70% resolve spontaneously. If the curvature is more than 30 degrees, there may be progression, and the prognosis is therefore guarded.
Postural compensation of the spine may lead to lateral curvature from such causes as unequal length of the lower extremities. Sciatic scoliosis may result from pressure on the spinal cord or roots by infectious processes or herniation of the nucleus pulposus; the underlying cause must be sought. The curvature will resolve as the primary problem is treated.
Treatment of scoliosis depends on curve magnitude, skeletal maturity, and risk of progression. Curvatures of less than 20 degrees usually do not require treatment unless they show progression
8. A 19 year old African-American college student comes to the student health center because of marked fatigue. Physical examination shows a temperature of 38.3 C (101.0 F) and striking pallor of skin, nail beds and conjunctivae. There are petechial hemorrhages in the skin of his legs. A soft blowing systolic murmur is present over the precordium. No other abnormalities are present. The most appropriate study at this time is
a) complete blood count
b) determination of bleeding and clotting time
c) examination of bone marrow aspirate
d) hemoglobin electrophoresis
e) serological testing for infectious mononucleosis
View Answer A: complete blood count
I agree with the anonymous poster in the newsgroup that the CBC is to characterize the degree of the patient's anemia (and platelet count) in this case. However, this patient appears to have a platelet disorder rather than hemorragic fever.
Excerpted from the Merk Manual with permission:
Platelet disorder:
Thrombocytopenia may stem from failure of platelet production, splenic sequestration of platelets, increased platelet destruction or utilization, or dilution of platelets. Regardless of cause, severe thrombocytopenia often results in a typical pattern of bleeding: multiple petechiae in the skin, often most evident on the lower legs; scattered small ecchymoses at sites of minor trauma; mucosal bleeding (epistaxis; GI and GU tracts, and vaginal bleeding); and excessive bleeding after surgery. Heavy GI bleeding and bleeding into the CNS may be life-threatening manifestations of thrombocytopenic bleeding. However, thrombocytopenia does not cause massive bleeding into tissues or hemarthroses, such as may occur in bleeding secondary to plasma coagulation factor deficiencies (eg, hemophilia).
A thorough drug history must be taken to rule out exposure to drugs known to cause increased platelet destruction in sensitive patients. About 5% of those receiving heparin may develop thrombocytopenia (see HEPARIN- INDUCED THROMBOCYTOPENIA, below). Thus, it is important to establish whether a patient is receiving heparin. Since this is neither dose- nor route-dependent, it can occur even with the mere use of very low doses as with heparin flushes to keep IV or arterial lines open. Other drugs that less commonly induce thrombocytopenia in sensitive individuals include quinidine, sulfa preparations, oral antidiabetic agents, gold salts, and rifampin. Because patients infected with the human immunodeficiency virus (HIV) may present with an isolated severe thrombocytopenia otherwise indistinguishable clinically from idiopathic thrombocytopenic purpura (ITP, see below), risk factors and history of other symptoms of HIV infection should be elicited. Other important points in a history may be a blood transfusion within 10 days (possible post transfusion purpura), significant alcohol consumption (possible alcohol- induced thrombocytopenia), and symptoms (eg, arthralgia, Raynaud's phenomena, unexplained fever) suggestive of an underlying immunologic disease.
Differential diagnosis: Presence or absence of fever is an important point; it is usually present in thrombocytopenia secondary to infection or active SLE and in thrombotic thrombocytopenic purpura (TTP), but absent in ITP and in drug-related thrombocytopenias. Size of the spleen on physical examination is a second important point. The spleen is not palpably enlarged in most thrombocytopenias caused by increased platelet destruction (eg, ITP, drug- related immune thrombocytopenias, TTP), whereas it will be palpably enlarged in patients with thrombocytopenia secondary to splenic sequestration of platelets, and often in patients with thrombocytopenia secondary to a lymphoma or a myeloproliferative disorder.
Laboratory findings: The peripheral blood cell count is a key examination not only for establishing the presence and severity of thrombocytopenia, but also for detecting clues to its cause. Platelet size should be noted; an increased proportion of large platelets (determined by scanning the blood smear or by measuring mean platelet volume [MPV] with an electronic blood counter) suggests compensatory increased platelet production. It is often found in thrombocytopenias secondary to increased platelet destruction or utilization. Since the bleeding time will be substantially prolonged in severe thrombocytopenia of any cause, it adds no information, but may provide useful information in the patient with a moderate thrombocytopenia (eg, a platelet count of 50,000/uL). A very long bleeding time suggests that the process causing the thrombocytopenia (eg, coating of platelets with antibody) has also impaired the function of circulating platelets. Other screening tests of hemostasis (see above) will be normal unless the thrombocytopenia is associated with another condition affecting hemostasis (eg, liver disease or DIC). Bone marrow aspiration provides the number and appearance of megakaryocytes, and confirmation of the impression gained from the peripheral blood smear of the presence or absence of disease causing marrow failure (eg, leukemia). Measurement of platelet-associated IgG may also be of value in selected patients. Regardless of the history of risk factors for HIV infection, serologic tests should be done with the patient's consent. If a patient receiving heparin becomes thrombocytopenic, a test for heparin-induced platelet aggregation or for heparin-dependent platelet release (of serotonin or ATP) should be carried out.
Treatment of thrombocytopenia varies with its cause and requires rapid identification of the cause and correction if possible (eg, discontinuing heparin in heparin-associated thrombocytopenia, recognizing and treating an infection causing gram-negative endotoxemia, inducing a remission in a patient with acute leukemia). When thrombocytopenia is secondary to decreased production, giving platelet concentrates will usually raise the platelet count for 2 to 3 days. Platelet concentrates should be used prophylactically with discretion, since their effectiveness may be lost with repeated use owing to the development of platelet alloantibodies. If rapid correction of bone marrow failure is not expected, platelet transfusions are often reserved for management of an active bleeding episode. Platelet concentrates should rarely be used prophylactically in patients with thrombocytopenia secondary to increased platelet consumption (eg, in ITP), since they will usually be cleared from the circulation within 1 to several hours. However, if a patient with ITP is experiencing serious mucosal or CNS bleeding (a medical emergency) then high-dose immune globulin is given IV followed by platelet transfusions. The platelet concentrates may be given continuously (1 to 2 u./h) or in larger amounts every few hours (eg, 6 to 8 u. q 4 to 6 h). Platelet concentrates should not be given (unless death from bleeding would otherwise ensue) in 2 thrombocytopenic disorders due to increased platelet consumption: heparin-induced thrombocytopenia and TTP. In these disorders transfused platelets may be incorporated into platelet-fibrin thrombi and thus trigger a serious thrombotic event.
HEMORRHAGIC FEVER WITH RENAL SYNDROME (HFRS)
(Korean Hemorrhagic Fever; Epidemic Nephrosonephritis; Nephropathia Epidemica)
An acute infection caused by species of Hantavirus, transmitted to man from rodents and characterized by renal involvement (nephritis) and hemorrhage.
Etiology and Epidemiology
The genus Hantavirus consists of at least 4 species: Hantaan virus (Korean hemorrhagic fever), Seoul virus (a milder form of Korean hemorrhagic fever), Puumala virus (nephropathia epidemica), and Prospect Hill virus (isolated from meadow voles in Maryland and not associated with human disease). Hantaviruses have been isolated from rodents throughout the world; 42% of Norway rats in Baltimore tested between 1980 and 1986 had antibodies to Hantaan virus. An increasing number of naturally acquired and laboratory- associated infections are being reported in Europe. The virus is present in the urine, feces, and saliva of various rodents, including field and laboratory mice, rats, and voles. Transmission from rodent to rodent is primarily respiratory, with transmission to humans through inhalation of infectious aerosols from rodent excreta. There is no evidence of human-to-human transmission.
Symptoms, Signs, and Laboratory Findings
A milder form of this disease was diagnosed in Scandinavia as nephropathia epidemica and is characterized by sudden onset of high fever, headache, backache, and abdominal pain. On the 3rd or 4th day, conjunctival hemorrhages, palatine petechiae, and a truncal petechial rash may appear. About 20% of patients develop a toxic condition and become mentally obtunded. Oliguria and azotemia develop concomitantly with the hemorrhagic manifestations. Urinalysis reveals proteinuria, hematuria, and pyuria. The rash subsides in about 3 days; the patient develops polyuria and recovers over several weeks.
In the more severe eastern form of HFRS, the clinical course may be divided into 5 phases: febrile, hypotensive, oliguric, diuretic, and convalescent. The incubation period is 7 to 36 days, usually 10 to 25 days. The severity of illness varies considerably; about 65% of cases are mild, while 10 to 15% are severe. The onset is usually abrupt (febrile phase) with chills, fever, backache, abdominal pain, and myalgia. The fever peaks on the 3rd or 4th day. There is a relative bradycardia. One of the most typical early findings is a diffuse reddening of the face, resembling a sunburn. Dermatographism can be demonstrated in > 90% of patients. Petechiae develop on the 3rd to 5th day, initially on the palate, then at pressure areas such as the axillary folds. Conjunctival hemorrhages appear at about the same time. Laboratory findings are unremarkable except for albuminuria, which appears between the 2nd and 5th day. The urinary sediment reveals hematuria and RBC and WBC casts. About the 5th day, shock or hypotension may occur (hypotensive phase); in mild cases, the fall in BP is only transient. At this stage, the Hct increases and marked proteinuria, leukocytosis, and thrombocytopenia develop. About the 8th day, BP returns to normal but oliguria develops (oliguric phase). BUN levels increase rapidly, and hemorrhagic manifestations become more prominent. Diuresis (diuretic phase) occurs about the 11th day, and CNS and pulmonary complications may be seen. The convalescent phase lasts 3 to 6 wk.
Prognosis and Treatment
Overall fatality in HFRS is 6 to 15%. Residual renal dysfunction is uncommon in Korea but may be more common in Europe.
Treatment involves meticulous supportive care. Renal dialysis may be required. Experimental trials suggest that ribavirin IV in dosage regimens similar to those used in Lassa fever may be beneficial.
9. A 17 year old high school senior comes to the clinic because of pain during her menses for the past 2 years. She describes the pain as crampy, felt in the lower abdomen and radiating to the back. She says it is most severe the second day of the flow and subsides thereafter. Her medical history shows that menarche was at age 14 years. Physical examination is normal. The most appropriate next step is to
a) begin a therapeutic trial of aspirin
b) begin a therapeutic trial of ibuprofen
c) determine serum CA-125 concentration
d) do diagnostic laparoscopy
e) do a dilatation and curettage
View Answer B: Begin a therapeutic trial of ibuprofen
From Chris:
Dysmenorrhea, aka "painful menstruation" is the chief complaint of this
17 y/o pt. She experiences a typically
lower abdominal pain consistently on the second day of menstruation, and
apparently at no other interval. The
pain irradiation to the back is probably a "red herring" as nothing else
in the Hx suggest otherwise.
Other remote possibilites on a differential dx of dysmenorrhea
(secondary):
* chronic PID - pt not sexually acive (?)
* intrauterine device
* leiomyomas - pt is too young
* endometriosis - " "
- interestingly enough this pt's menarche was 2 years ago, primary
dysmenorrhea usually presents 2 years after
the onset of menses.
*******************************
An NSAID trial could prove beneficial since the cause for this type of
"painful menst" is thought to be secondary
to Pg-induced myometrial contractions.
Estrogen therapy is an alternative, although beginning Ibuprofen a few
days before the anticipated menses can often help.
******************************
If the pt were older the endometriosis (a known cause of 2ary
dysmenorrhea) would have been given greater consideration, and
particularly if she had a Hx of "infertility."
- CA-125 is often a "false +" in pre-menopausal women !!
10. A 21 year old man comes to the clinic because he has become increasingly short of breath and has had a cough for the past week. He appears dyspneic and has a temperature of 38.3 C (101.0 F). On physical examination he has bibasilar rales and genearlized lymphadenopathy (1 to 2 cm). Rectal examination shows multiple perianal contusions and a small amount of blod oozing from the anal orifice. A chest x-ray film shows bilateral patchy alveolar infiltrates. The most appropriate course of action is to order blood tests and to
a) admit him to the hospital and begin administration of trimethoprim-sulfamethoxazole, intravenously
b) admit him to the hospital and begin administratio nof penicillin and gentamicin, intravenously
c) begin adminstration of erythromycin, orally, and see him again the next day
d) prescribe isoniazin and rifampin, orally
e) recommend aspirin, fluids and rest at home
View Answer A: admit, start on tmp-sulfa IV.
Explanation courtesy of Chris of the Newsgroup.
- A 21 y/o pt with fever, SOB, cough (non-productive ?), and lymphadenopathy initially suggests Infect. Mono, although we are not informed if there is splenomegaly.
- bibasilar rales indicate a pneumonic process, maybe asociated with the other findings. Viral ? EBV ?
- by virtue of the DRExam, we can assume that this patient is a practicing homosexual. Now the differential dx should include R/O Hiv(+), AIDS, and PCP,the latter which could account for the fever, increasing SOB & cough, although the CXR is not typical of the diffuse INTERSTITIAL infiltrates caused by P. carinii.
If you consider AIDS on the list of dx, then the lymphadenopathy could be 2ndary to lymphoma, syphilis etc.
*********************
As far as mgmt is concerned, this pt must be assumed to have PCP and must receive Bactrim. (A
Click here for questions 6-10
11. A 29 year old Italian-American woman comes to the office for her first prenatal visit. Her last menstrual period was 16 weeks ago. This is her first pregnancy; her family history is unremarkable. She has heard that people of Mediterranean ancestry are at risk for carrying a gene for ß-thalassemia. She asks to be tested for this. The most appropriate initial diagnostic study is
a) complete blood cell count with red cell indices
b) hemoglobin electrophoresis
c) red cell osmotic fragility test
d) restriction-fragment length polymorphism (RFLP) analysis of her ß-globin gene
e) reticulocyte count
View Answer A: complete blood count with red cell indicees
Erythrocytes of the beta-thalassemia heterozygote have an MCV of 55 to 80 fl and a corresponding reduction in MCH. The RDW is normal in contrast to iron deficiency anemia, in which it is high. People who are silent carriers can have a normal MCV value. The red cell count is often elevated and the blood film commonly shows target cells and basophilic stippling (Plate III-4, M). Reticulocyte counts may be elevated (2% to 3%), but this is an inconsistent finding. Detection of most heterozygotes is simplified by the presence of an elevated HbA2 level (4% to 6%), which is most accurately measured by column chromatography. HbF level may be slightly increased (1% to 3%). In delta-beta-thalassemia carriers, the HbA2 level is normal or reduced, and the HbF concentration is increased (5% to 20%).
Homozygotes are severely anemic with hemoglobin levels of less than 5 g/dl in the absence of transfusion. MCV and MCH are reduced, and the reticulocyte count strikingly elevated. The blood film findings are characterized by nucleated red cells, Pappenheimer and Howell-Jolly bodies, marked anisocytosis, poikilocytosis, and polychromatophilia. The bone marrow is hypercellular with marked erythroid hyperplasia and increased iron stores. Heinz bodies can be demonstrated by special staining methods (Plate III-4, P). Fetal hemoglobin is the major hemoglobin component, with absent or very reduced levels of HbA. The HbA2 level shows considerable variation. Other indicators of chronic hemolysis are present, such as unconjugated hyperbilirubinemia, elevated LDH level, and decreased haptoglobin. Radiography of the skull may show the "hair on end" appearance of an enlarged diploic space, and other bones may appear osteoporotic.
Differential diagnosis
The heterozygous beta thalassemias may be confused with iron deficiency and other microcytic anemias. There are few disorders that may be confused with the severe homozygous beta thalassemias. Improperly managed patients with serious growth retardation, impaired nutrition, and marked hepatosplenomegaly superficially resemble individuals with advanced cirrhosis of the liver or malignancy.
Treatment
Heterozygous beta thalassemias require only recognition, so that iron is not injudiciously administered, and carriers can be offered counseling. Screening programs, based on the detection of microcytosis and presence of elevated HbA2 levels, are practical in groups with a high disease prevalence. When a family is at risk for having homozygous offspring, prenatal diagnosis is possible. In parts of Greece, Italy, and Cyprus, screening, counseling, and prenatal diagnosis have led to a nearly 100% reduction in the numbers of homozygotes born.
Intensive transfusion therapy and chelation of excessive iron have improved the management of severe disease. When transfusion is started very early in life and the hemoglobin levels are kept at 9 to 10 g/dl, erythropoiesis is suppressed, marrow expansion does not occur, severe hemolysis is not present, and growth and development are near normal. Besides the usual complications of transfusion, such as alloimmunization and transmission of retroviral infection, the iron burden, deposited in tissues as a result of the destruction of transfused blood, must be removed by chelation to prevent the development of transfusion-induced hemochromatosis. Desferrioxamine (Desferal), a chelating agent, is given by prolonged subcutaneous or intravenous infusion, 8 to 12 hours nightly, 5 to 6 days weekly, at doses of 2 to 6 g/day, using a portable infusion pump. The regimen must be tailored to each individual as the amount of iron excreted varies. Although optimum chelation therapy can induce negative iron balance, the ultimate effects of this treatment are not yet known. When treatment is started after significant iron accumulates, the cardiomyopathy may not always be reversible and is a leading cause of death, although intense chelation may reduce the prevalence of arrhythmias and congestive failure. Ideally, chelation should be started in young children before the acquisition of excessive iron stores. Low doses of vitamin C may increase the excretion of iron by desferrioxamine and can be used in vitamin C depleted individuals while they are receiving chelation treatment. An effective oral chelating agent that provides relief from the arduous regimen of subcutaneous infusion may soon be available.
Splenectomy may be performed when the red cell survival shortens. This reduces the excessive red cell destruction and cytopenias of hypersplenism and lengthens the interval between transfusions. Severe postsplenectomy infection is a risk that must be weighed and argues for delaying surgery as long as possible. Polyvalent pneumococcal, Haemophilus influenzae and Neisseria meningitidis vaccine should be given before surgery and prophylactic penicillin afterward.
Bone marrow transplantation has been employed in severe beta thalassemia and considerable experience has been gained in Italian centers. It is the sole way to eradicate the disease. However, the best candidates are the youngest children, as older, more heavily transfused patients are less likely to become engrafted and have higher morbidity and mortality. Because transfusion and chelation can allow normal development and a decent quality of life for many years, and because bone marrow transplantation still has appreciable short-term mortality, the decision to recommend this therapy has been very difficult. However, in children who have little or no liver disease as a result of efficient chelation, transplantation using haploidentical donors results in a disease-free survival rate of 95%. If these results are replicable, then early transplantation may be the most efficacious and cost-effective method of treatment and free the patient from the lifelong burden of parenteral chelation therapy. If the promise of an effective oral chelating drug is realized, the arguments regarding early transplantation may have to be reconsidered.
Preliminary studies have suggested that hydroxyurea may increase the level of HbF and raise the hemoglobin level in some individuals with severe beta thalassemia. This therapy may be enhanced by the administration of erythropoietin. These are exciting experimental observations but await further study before their use can be recommended. Further over the horizon are other HbF-inducing agents, such as butyrate analogs, and means of altering the genetic defects of thalassemia by gene therapy.
12. An 84 year old woman is brought to the office by her daughter, who is your patient. The mother has just moved in whith the family because she can no longer take care for herself due to progressive, long-standing dementia. The daughter hopes you will help take care of her mother. On physical examination the mother has no evidence of any other chronic disease. She does not respond to your words or to the physical examination. You notice that she smells of urine. On examination of the pelvis there is a diffuse erythematous rash extending over the prineum to the medial thighs bilaterally. You suspect the rash relates to urinary incontinence. The daughter is present at the mother's examination. The best opening remark to the daughter is:
a) "You should take better care of your mother"
b) "How long have you left your mother in this condition?"
c) "Your mother needs to wear diapers"
d) "This rash should respond to cleansing with mild soap and drying with a clean towel three times a day"
e) "This is a rash caused by urine. My nurse wll insert a Foley catheter"
View Answer D: "This rash should respond to cleansing..."
13. A 67 year old woman, who is a regular patient, calls the office complaining of severe muscle weakness, polyuria and muscle cramps. She began treatment 6 weeks ago with 50 mg of chlorthalidone daily for mild-to-moderate essential hypertension. The most likely explanation for her symptoms is the development of
a) hypokalemia
b) hypomagnesemia
c) hyponatremia
d) metabolic acidosis
e) noninsulin-dependent (tyype II) diabetes mellitus
View Answer A: Hypokalemia
For an explanation of this answer you can go to http://www.studynow.com and visit the section on search drugs (search for chlorthalidone).
Explanation by Chris:
67 y/o female has received 6 weeks of CHLORTHALIDONE (at the appropriate dose of 50mg QD) for her Hypertension, presents with acute/sudden onset ?? of muscle weakness, cramps, and polyuria.
- we are not given the actual period of the onset of symptoms, but the introduction implies that this is a recent occurence.
- chronic use of diuretics certainly causes hypokalemia, but symptoms such as the muscle weakness and cramps experienced by our patients appear at levels less than 2.5mEq.
* Hyponatremia also figures into the list of possible causes, but many patients are asymptomatic even with levels of 130mEq, and when do they do develop the forementioned symptoms it is often accompanied by an altered mental status, this patient seems to be fully alert and oriented relegating this possibility after HypoK+ on the differ dx list.
* Hypomagnasemia is not likely to occur ithis patient (ie. NO hyperalimentation) and she does not present with the typical manifestations of the associated hypocalcemia: fasciculations, Chvostek, and Trousseau. Therefore this lyte disturbance is also not very likely.
* diabetes is a rather remote possibility as this pt seems to have been closely followed as the history suggests with no documentation of any associated findings. A presentation this late in life is highly unusual. We have Not enough evidence to incriminate diabetes.
* metabolic acidosis is also unlikely, as there is no identifiable cause for this complication.
- the polyuria "may" be expected, as some patients admit to "increasing their diuresis" after receiving this class of meds.
*******************************
Hypokalemia is the most probable offender (A).
14. A 71 year old retired publisher comes to the office for her annual health maintenance visit. She is in good health and has no complaints. On pelvic examination she has a 10-cm firm mass in her right adnexa, which has both cystic and solid components on ultrasonography. The most appropriate next step is to
a) aspirate the mass under ultrasonic guidance
b) obtain a carcinoembryonic antigen (CEA) tumor marker
c) reexamine her in 3 months
d) schedule diagnostic laparoscopy
e) schedule exploratory laparotomy
View Answer E: Exploratory laparotomy
From Chris:
71 y/o pt on her annual health exam; asymptmatic. P.E. significant for a
10 cm right adnexal mass, with both cystic-solid components.
*********************
Post-menopausal pt with a large adnexal mass. This ominous finding
demands of us to R/O an ovarian neoplasm as our first and foremost
priority. Nonetheless other causes exist:
- Uterine Leiomyomas (affectionately known as "myomas")
- Colon CA
- Retroperitneal Tumor
- "Full bladder"
- "Feces in colon
Myomas in this pt are ruled out by virtue of (-) U/S findings. The pt is
described as being in "good health," and we can assume in this case that
no weight loss has occured.. therefore if a retroperitonal neo
(Pancreatic CA) that size would most certainly have caused this woman to
be cachetic and symptomatic (ie. jaundice), she's not. Colon Ca, not
likely since again there is no history of weight loss, pain or anemia
(expected of an advanced Right-sided Colon CA). Thus our dx is R/O
Ovarian (malignant) neoplasm.
***********************
There is a general consensus among Gynecologists to remove ALL masses
in postmenopausal women due to a rather relatively "high" frequency of
malignancy. An indication for removal of a suspected ovarian mass is
"persistence of several months" and ">8cm diameter." The answer is (E)
exploratory lap.
***********************
The cystic-solid (loculated) nature of the mass in question points to
the following ovarian tumors as suspects:
Benign and more frequent: mucinous cystadenoma, serous cystadenoma >>
cystic teratoma (aka "dermoid cyst")
Malignant & less frequent: mucinous cystadenoCA, serous adenoCA
***********************
***********************
Clinical Pearl:
- prepubertal female with pelvic mass: R/O germ-cell tumor (50%
malignant), therefore malignant until proven otherwise.
- reproductive age " " ": observe mass for >1 menstrual cycle (ie.
functional follicular cyst vs..)
- postmenopausal " " ": remove all masses.
+ 80% of all Ovarian CAs are benign.
15. A 4 year old boy is brought to the office because he has become unmanageable at his day-care center. You have examined him two other times during the past year because of short stature. At those visits he exhibited some behavior problems which his mother did not set limits. He constantly interrupted situations, seeking his mother's attention. She now reports that during the past few months his fighting, refusal to obey the day-care workers and violations of "time out" have become much worse. He began to attend day-care at 6 weeks of age so that his mother could return to work. Because his parents work long hours, he is often cared for after day-care by any other of several relatives. His father did not finish the ninth grade and now works as a house painter; he is alcohol-dependent. The boy has a 6-month old sister who also attends the same day-care center. Records show his height and weight ar at the 5th percentile, and his growth velocity is normal. There were no complications during the pregnancy with this child and he has not had any significant medical problems. His physical examination today is normal. The most likely cause for this child's worsening behavior is
a) aggressiveness to compensate for a poor self-image cause by short stature
b) attention-deficit/hyperactivity disorder due to inherited factors
c) a reaction to his father's drinking
d) reduction in his mother's attention because of his new sibling
e) a toxic reaction to organic fumes from his father's clothes and work materials
16. A 76 year old woman returns to the office because of aching and weakness in her arms to the point where she cannot lift them to brush her hair. Physical examination shows no muscle tenderness or other evidence of joint disease in the upper extremity. The aching improves when she takes the prescribed nonsteroidal anti-inflammatory drug (NSAID). She also describes localized scalp tenderness over the right parietal area. Physical examination of the scalp shows no lesions. The most appropriate next step would be to
a) increase the dose of the NSAID
b) order determination of erythrocyte sedimentation rate
c) order determination of rheumatoid factor
d) order x-ray films of the cervical spine
e) refer her for psyciatric counseling
View Answer B: Order ESR
Explanation by Chris:
76 y/o woman presents with "aching" & "weakness" in her arms...
apparently with difficulty raising small objects and perform light
exercise. Pt reports "scalp tenderness." Admits to improvement with
NSAIDs. PMHx is negative. P.E. is apparently unremarkable.
- We should ask for how long as this complaint been present ?
- Its onset ? Duration (constant vs. occasional) ? Weight loss ? H/A ?
************************************
Entities which should arouse our suspicion:
- Rheumatoid Arthritis ??
- Polymialgia Rheumatica
- Giant Cell Arteritis (Temporal Arteritis)
- Polymiositis
************************************
We will first R/O the most common causes first...
- R/A: no joint pain, limitation is noted, and since the PE is
apparently negative, we assume that no nodules our observed as are other
manifestations of R/A -- essentially ruled out.
- PM: the complete PE (including neuro exam) would have detected any
proximal muscle weakness, any tenderness or muscle atrophy...none is
documented, and no skin lesions (ie. knuckles) described... just in case
an associated dermatomyositis were to be expressing itself, thus PE is
relegated to the bottom of the Diff Dx list.
- PMR-GCA: can manifest itself with weakness, usually with the shoulder
girdle being most affected (A point in favor), improvement with NSAIDs
(A point in favor), and scalp tenderness (A point in favor)... WE ARE
OBLIGED TO INTERROGATE FOR H/A AND JAW CLAUDICATION (ie. during chewing)
..but MOST IMPORTANTLY... LOSS OF VISON !!!
$ BTW Some researches have postulated that PMR and GCA are the same
disease process, but different stages.
*************************************
We now seem to have our culprit... PMR - GCA. Therefore (B) "ESR" is
the best answer, although I believe that we would all agree to begin a
course of prednisone stat before the patho report of an obligated
temporal artery biopsy were available.
- Chris
17. (17-18) A 38 year old homemaker and mother of four children (ages 5-12 years) has been coming to you for tension headaches that have not improved much with trials of several appropriate medications. She has been married to a policeman for the past 6 years. You ask if she has been under extra stress, and she begins to cry. You notice bruises on her arms. On further questioning, you learn that her husband hits her whenever he is drunk, which is at least 2 nights per week. She syas, "he is nice...a good husband when he's sober. But when he drinks, oh he's awful! He accuses me of cheating on him. Last night he said he would kill me if I try to leave." Her husband is also a patient of yours.
17. The most appropriate intervention would be to
a) advise her to leave her home with her children and move in with her relatives
b) contact her husband's supervisor to discuss recent stress levels on the job
c) gather more information while remaining neutral, since both the husband and wife are your patients
d) refer her to a battered women's program
e) seek a restraining order against her husband on her behalf
View Answer d: Refer her to a battered women's program
18. The most vital question to ask at this time is:
a) "Do you think this might be causing your headaches?"
b) "Has your husband also lost his temper with any of the children?"
c) "Have you been drinking at the time of the fights?"
d) "Have you or your husband been receiving any kind of counseling?"
e) "Why have you stayed in this marriage?"
View Answer B: Has your husband lost his tember with any of the children
19. This question requires viewing an x-ray; thus it will be skipped for now.
20. (20-21) A 27 year old man comes to the office because of a 1-week history of right knee pain. He says he has an exercise routine that includes jogging 3 miles a day and that the pain in his knee worsens during his run. On physical examination his gait appears to be normal. Examination of the knee reveals tenderness and fullness over the medial collateral ligament.
20. On physical examination there is most likely to be
a) increased anterior laxity with anterior pressure on the tibia
b) increased posterior laxity with posterior pressure on the tibia
c) a painful clicking sensation with inward rotation of the foot and extension of the knee
d) pain during forced abduction of the leg below the knee
e) pain during internal and external rotation of the tibia while compressing it against the femur
View Answer D: Pain during forced abduction of the leg below the knee
21. The most accurate statement concerning this patient's condition is that he will need
a) to choose a different type of activity for his exercise program
b) initial treatment with rest, ice packs and isometric exercises
c) treatment with knee immobilizaton and crutches
d) referral for an orthotic device
e) referral for arthroscopy
22. A 69 year old Chinese-American man with diabetes mellitus had a myocardial infarction 2 years ago. He has had exertional angina since then and has been taking propranolol. During the past few days he has had one episode of pain at rest, two episodes postprandially and one at night. The electrocardiogram is unchanged. The preferred treatment would consist of
a) admitting him immediately for cardiac monitoring and adjustment of therapy
b) admitting him immediately for coronary artery bypass surgery
c) decreasing the dosage of propranolol and adding nitrates and salicylate
d) increasing the dosage of propranolol and having him return in 1 week
e) resting from work, sedation at night and digitalization
View Answer A: admitting him immediate for cardiac monitoring and adjustment of therapy
Chis Responds:
69 y/o pt with a PMH significant for past MI 2 years ago and exertional
angina thereafter. Consults for:
* increase in number of episodes
* apparition of angina at rest.
*******************************************
This pt's course has rapidly accelerated within the past few days and
can now be considered to have "Unstable Angina." By all means keep the
Beta-Blockers. Its well-known that these meds decrease the risk for
future cardiac events.
*******************Answer is (A)**********************
He must first be admitted to document any ischemic changes, and in what
area(s)/territories they are taking place.
******************************************************
I would then add nitrates to this pt's anti-anginal regimen, and if he's
not receiving ASA (300mg) add that as well... but taking into his
history of known MI, I might be hesistant to wait for another
potentially lethal anginal episode and begin treatment ASAP.
In light of his rapidly progressive course I would like to cath this
fellow, and keep the CABG as a later option depending on how many
vessels are compromised.
* Pearl: if only 1-2 vessels is severely affected then PTCA
" > 2 " then CABG.
Taken from the EAST trial at Emory U., Atlanta.
23. A 38 year old woman who is single mother of two small children comes to the office saying that she feels "halfway tired all the time." Her physical examination is unremarkable and unchanged from 1 year ago. Toward the end of the visit she says anxiously, "My children just don't listen. They make me so angry that I feel out of control sometimes." She pauses. "Yesterday my 7 year old daughter talked back to me and I slapped her in the face." Her eyes fill with tears. The most accurate statement concerning this patient is that she
a) should be reported to child abuse authorities
b) was clearly a victim of child abuse herself
c) would benefit from antidepressant medication
d) would benefit from family counseling
e) would exhibit better self-control if she were married
View Answer D: would benefit from family counseling
24. A woman telephones because her 7 month old infant is irritable and has a temperature of 39.6 C (103.2 F) with persistent vomiting. Upon questioning, she reports that the infant's neck is supple. Further diagnostic work-up should be based on the need to rule out
a) bacterial meningitis
b) bacterial pneumonia
c) hamartoma of the hypothalamus
d) herpetic encephalitis
e) viral respiratory infection
View Answer A: bacterial meningitis
Chis Responds:
7 m/o infant's mother consults for:
- Fever (39.6 C)
- irritability and vomiting
******************************
This ominous triad should obligate the MD who first sees this child to
R/O Meningitis first and foremost since this is treatable disease, and
the implications of a delayed diagnosis are grave. (A)
According to the baby's age: hemphilus influenze is a prime suspect as
the irrepresable pneumococcus and meningococcus are less frequent in
this age.
Why not ask "Mom" if junior has had fever prior to the present syndrome
? If the pt was older I would ask for "earaches" too.
Pearl: Otitis media + meningitis --> R/O Hemophilus Influenzae.
As far as a PE goes, an otoscopy in an irritable infant is very
difficult and often poorly done, but it can provide an important clue as
to the etiology of the meningitis. In any case an L.P. is warrented and
will ultimately reveal the culprit's identity.
The baby's fontanelle might be bulging, but outright signs of meningism
(ie. nucal rigidity) are infrequently observed in infants.
Ceftriaxone is the abx of choice.
****************************************
Why the other aren't:
- encephalitis: no signs of focalization &/or convulsions (can occur in
bacterial meningitis as well)
- Viral URI: no cough, rinorrhea are documented
- pneumonia: no respiratory distress noted
- hamartoma of the hypo: ???
25. (25-26) Earlier today, you examined a 16 year old boy who came to the office for a school physical examination. He had no complaints or medical problems. He said he is sexually active, has had three different sex partners and that he "sometimes" uses condoms. He had no complaints of dysuria or penile discharge. You know that he would be reluctant to consent to evaluation for asymptomatic urethritis with urethral swabs because of fear of discomfort. In trying to determine how to screen for this prevalent problem, you recall a recent study that compard a new urethritis screening test -- the first part voided urine (FPV) -- to the "gold standard' of urethral culture. In this study, 50 asymptomatic male adolescents provided the first 10 mL of a voided urine specimen (FPV), and urethral swabs were taken for culture of Chlamydia trachomatis and Neisseria gonorrhoeae,. The FPV specimens were spun down, and the sediment was examined microscopically under high power. Twenty-one of 23 (91%) subjects whose FPV showed more than 10 WBC/hpf had positive urethral culture for C. trachomatis or N. gonorrhoeae compared with only 1 of 27 (4%) FPV negative subjects with a positive culture.
25. The most accurate statement about the data is:
a) The FPV is not a helpful screening test because its sensitivity depends on the frequency of urethritis
b) The FPV is not a useful screening test because of its low positive predicitive value
c) No conclusions can be drawn from the data because the samble size is insufficient
d) The sensitivity of the FPV in identifying culture positive urethritis is greater than 90%
e) The specificty of the FPV in identifying patients who do not have urethritis is less than 90%
View Answer D:
26. For a variety of reasons you decide not to institute the FPV as a screening test in your practice. In coming to this decision, you have realized that the most important factor contributing to the positive predictive value of the FPV is the
a) correlation coefficient
b) incidence of urethritis in your patient practice
c) lack of reproducibility
d) prevalence of urethritis in your patient practice
e) reliability factor of the test
View Answer D:
27. A 45 year old man comes to the office for a follow up visit. He has a history of low back pain following a lifting accident at work 3 years ago. Until now his pain has been confined to the lumbosacral region, and he has had no numbness or presthesia in his lower extremities. Today he reports a sensation of pain shooting down the posterolateral aspect of his left thigh, extending medially to his left great toe. The pain is made worse by coughing. The patient's history suggests
a) actue muscle strain
b) chronic lumboscral strain
c) degenerative lumbosacral arthritis
d) intervertebral disc herniation
e) spinal stenosis
View Answer D:
Acute lumbar disk herniation, rupture, or extrusion represents an acute episode in a chronic degenerative process. Patients may have a history of chronic episodic low back pain.
Diagnosis
Pain usually begins abruptly, often with trivial trauma such as sneezing. The pain is often described as stabbing or shooting, worse with sneezing or coughing, and often incapacitatingly severe. Radiation in the distribution of the sciatic nerve is common. The physical findings are similar to those of degenerative disk disease, with the addition of severe paravertebral muscle spasm. Sciatic stretch tests may be positive. Neurologic function, including sensation and deep tendon reflexes, is intact. X-rays and the results of laboratory studies are usually normal.
Treatment & Disposition
Acute lumbar disk herniation usually requires complete bed rest and narcotic analgesics (for the first day or so). Additional measures are as described for chronic degenerative disk disease, above (ie, aspirin, nonsteroidal anti-inflammatory agents, muscle relaxants). Unless ideal support is available at home, the patient requires hospitalization. Bed rest is frequently required for 3-4 weeks, although most patients are significantly improved within 2 weeks.
28. A 67 year old retired carpenter who has been you patient for many years calls the office to complain of a new symptom. He says that when he walks fast or wlaks uphill, usually while playing golf, he has pain in his left calf that disappears with rest. He is overweight, he smokes cigarettes, and he drinks one beer on weekdays and two six-packs on the weekend. You have been treating him with lovastatin for a slightly elevated serum cholesterol concentration. He has never been able to follow your prescribed diet very well. You can tell this patient that the most likely reversible factor related to his pain is his
a) cigarette smoking
b) intake of saturated fats in his diet
c) use of alcohol
d) use of verapamil
e) weight
View Answer A:
Explanation by Chris:
67 y/o pt with PMH significant for obesity and hypercholesterolemia,
smoking presents with recent acute onset of unilateral calf pain while
making a slight - medium effort walking, that resolves spontaneously
with rest.
***********************
Dx: Pveripheral Vascular Disease.
***********************
Risk Factors:
- Diabetes Mellitus
- Hypercholesterolemia
- Smoking
***********************
We are not informed of any PE findings, such as skin discoloration on
the affected extremity, femoral-popliteal-pdeial pulses, bruits, pallor
of extremity when elevated etc..A treadmill test might be helpful to
document first hand the condition, and a Doppler-Duplex study as well,
although this pt may require an invasive study (ie. angiography) to
determine the extent of atherosclerotic compromise. If severe he may
ultimately be subjected to a SRV or PTA.
Tx: Cessation of smoking, exercise therapy, improve lipid profile and
Trental (pentoxiphylline).
Px: Only 50% pts have this condition stabilize or improve. 50% have
coexistent CAD.
Chris
29-30. A 17 year old boy is brought to the office by his mother who says that he has been increasingly withdrawn and preoccupied for several weeks. He has been sleeping poorly nad has refused to leave the house for the past week because he believes he is being followed. When his father insisted he attend school this morning, the patient threatened him with a knife. The patient is sweating, has dialated pupils and is obviously fearful.
29. Rapport with this patient can be best established by asking:
a) "Are you hearing voices?"
b) "Do you have a special mission to accomplish?"
c) "Do you think you are being persecuted?"
d) "How do you feel others are treating you?"
e) "Who do you think is following you?"
View Answer D:
30. After admission to the hospital, the most appropriate first intervention is to
a) administer haoloperidol
b) arrange a conference with the family
c) order CT scan of the head
d) order toxicologic screening of the urine
e) prescribe diazepam therapy, intramuscularly
31. A 50 year old African American man with severe chronic obstructive pulmonary disease returns to the office following a recent evaluation for possible lung transplantation to be done in another city. He says he has been considered a suitable candidate in all respcts, but was rejected by the transplant program when a random urine screen was positive for a nicotine metabolite. He had previously told you that he had stopped smoking 3 years ago. He stands by this and is at a loss to explai
1. A 23-year-old registered nurse comes to the employee health clinic because she says, "I'm too tired to work." She has had increasing fatigue, malaise and anorexia during the past several days. Her serum bilirubin concentration is 1.8 mg/dL, prothrombin time is 13 sec, serum alanine aminotransferase (ALT) concentration is 1160 U/L and a screening test for hepatitis B surface antigen is positive. She is instructed to rest at home and return in 3 days if no new symptoms develop. Two days after the visit she calls to say that she has now developeed an urticarial rash and swelling of the joints of her fingers. At this time the most correct statement about her condition is:
a) The arthritis and rash are the result of an associated immune complex disorder
b) The arthritis and rash are unrelated to her liver disease
c) It is unlikely that her blood is infectious
d) She has a 50% risk for developing chronic liver disease
e) She should be given hepatitis B immune globulin
View Answer A: Associated autoimmune complex disorder
Chronic active hepatitis of unknown etiology ("auto-immune" or "lupoid" chronic hepatitis)
This classic form of chronic active hepatitis (CAH) cannot be attributed to any known cause, and the original histologic classification referred to earlier was developed primarily in studies of this entity. First described by Waldenstrom in 1950 and Kunkel in 1951, the disease was thought to occur primarily in young women and demonstrated many autoimmune characteristics, including a positive lupus erythematosus (LE) cell phenomenon. It is now recognized that the disease occurs in persons of all ages and both sexes. Endocrine abnormalities (amenorrhea, hirsutism, acne, obesity, cushingoid facies, pigmented abdominal striae) and the LE cell phenomenon occur in only a small minority of patients and correlate with severity of disease rather than indentifying a unique subgroup. In contrast to chronic hepatitis B, which typically affects men, 70% to 80% of the patients are women. In one third of patients, the initial disease is identical to acute viral hepatitis. The remainder present insidiously with nonspecific symptoms of malaise, fatigue, and anorexia; are identified serendipitously on a random serum chemistry drawn for other reasons; or present with fully developed complications of advanced liver disease (ascites, variceal bleeding, hepatic encephalopathy). At least 85% of the patients have no history of exposure to jaundiced persons or other hepatitis risk factors.
Common clinical features on presentation include progressive jaundice, severe anorexia, malaise and fatigue, asymptomatic hepatosplenomegaly, and abdominal pain. Less common (20% or less) are epistaxis, acne, persistent fever, and tender hepatomegaly. Extrahepatic manifestations may occur in 20% to 25% of patients, with arthralgias and skin rashes the most common. Other abnormalities include thyroiditis, ulcerative colitis, pleurisy, pericarditis, myocarditis, and pulmonary complications, including fibrosing alveolitis. Isolated occurrences of lichen planus, mixed connective tissue disease, macroglobulinemia, and uveitis have been recorded. The multitude of disparate findings further support the likelihood of an immune origin for this disease, but it should be noted that some of these immune abnormalities (skin rashes, glomerulonephritis, arthritis) can be found in chronic hepatitis B due to immune complex desposition.
HBsAg-The appearance of HBsAg is the first evidence of HBV infection, appearing before biochemical evidence of liver disease. HBsAg persists throughout the clinical illness. Persistence of HBsAg after the acute illness may be associated with clinical and laboratory evidence of chronic hepatitis for variable periods of time. The detection of HBsAg establishes infection with HBV and implies infectivity.
HBV is usually transmitted by inoculation of infected blood or blood products or by sexual contact and is present in saliva, semen, and vaginal secretions.
Related topics:
Chronic active hepatitis C
Up to 60% of patients with post-transfusion hepatitis C develop chronic liver disease. Most often, the patient is only mildly symptomatic and nonicteric. Transaminases range from 200 to 800 and may show marked fluctuations, with rapid rises and falls and intervening periods of normality. Although post-transfusion hepatitis C affects men and women equally, 75% of those developing chronic hepatitis in one study were men. Similar to chronic hepatitis B, serum autoantibodies, hypergammaglobulinemia, and stigmata of chronic liver disease are rare, although a false-positive test for antinuclear antibodies may be present in some cases, leading to confusion with autoimmune hepatitis.
No good prospective histologic data are available in this group of patients, but CAH (usually without bridging or cirrhosis) is most common. Although it was initially thought that chronic active hepatitis C was a relatively benign disease, there is increasing evidence of slow progression to cirrhosis and liver failure. At least 20% of patients with CAH progress to cirrhosis within 5 to 10 years. Hepatitis C is the most common cause of cryptogenic cirrhosis and a common reason for liver transplantation in the United States. A strong association with the development of hepatocellular carcinoma is also recognized, with a particularly high correlation in Japan and Spain. Hepatitis A and hepatitis E do not produce CAH or CPH, and hepatitis D produces these lesions only in patients also infected with hepatitis B. In the latter instance, the frequency and severity of chronic hepatitis is greater than with hepatitis B alone.
2. A 19-year old archeology student comes to the student health service complaining of severe diarrhea with fifteen large-volume watery stools per day for the past 2 days. She has had no vomiting, hematochezia, chills or fever, but she is very week and very thirsty. She just returned from a 2-week trip to a remote Central American archeological research site. Physical examination shows temperature 37.2 C (99.0F), pulse 120/min, respirations 12/min and blood pressure 90/50 mm/Hg. Her lips are dry and skin turgor is poor. The most likely cause of the diarrhea is
a) anxiety and stress from traveling
b) inflammatory disease of the large bowel
c) poor eating habits during her trip
d) an osmotic diarrheal process
e) a secretory diarrheal process
View Answer E: Secretory diarrheal process
Increased fecal water content can result from either a decrease in the amount of fluid absorbed or an increase in the secretion of fluid sufficient to overwhelm the absorptive capacity of the bowel distal to the secretory site. Decreased absorption of fluid can occur as a result of (1) inability to absorb osmotically active solutes, which subsequently retain water in the lumen of the gut (Chapter 42); (2) lack of contact between intraluminal contents and absorptive surfaces; (3) change in active ion transport; and (4) increase in tissue hydrostatic pressure.
Osmotic Diarrhea Secretory Diarrhea
Laxatives
Malabsorption
Bacterial Endotoxins
Vasointestinal Peptide
Merck Manual Recommended Reading for Question 2:
DIARRHEA
Etiology and Pathophysiology
Complications of Diarrhea
Diagnosis
Treatment
3. A 64 year old white man comes to the clinic because of chest pain for the past 2 months. He has had intermittent episodes of substernal pain that occur at various times of the day and last 5 to 10 minutes. Physical examination is normal as is an electrocardiogram. The next step in evaluating his symptoms should be to order
a) a chest x-ray film
b) echocardiography
c) an exercise stress test
d) upper gastrointestinal endoscopy
e) 24-hour monitoring of cardiac rhythm
View Answer C: Exercise stress test
The main indication for exercise testing is to assist in the diagnosis of coronary artery disease in patients with chest pain. A second major indication is to evaluate functional capacity and aid in assessing the prognosis of patients with known coronary artery disease. When exercise stress is sufficient to produce a mismatch between myocardial O2 supply and demand, myocardial ischemia will develop and often is identified by certain alterations in the ECG's S-T segment. Although anginal chest pain induced by the test is strongly predictive of coronary artery disease, 1.0 mm of horizontal or downsloping S-T segment depression is considered a positive end-point for ischemia. The S-T depression must persist for 80 milliseconds (ms) or longer and must be recognized in at least three consecutive beats with a steady ECG baseline. Increasing S-T segment elevation can often be seen in leads demonstrating pathologic Q waves at rest in patients with prior myocardial infarction. These changes are predominantly observed in patients with a depressed ejection fraction and severe regional myocardial asynergy.
Quoted from the message group:
Effort testing is the way to go here
by IMG in distress!
Given the patient's symptoms and demographics, the most important thing to exclude would be ischaemic heart disease. In the absence of abnormal clinical features or dysrhythmia, investigations such as echo or CXR would be second line. Thus, to delineate the patient's response to an effort test would be the initial workup. Even in the event of there being an underlying occlusive/stenotic coronary lesion, the stress EKG would only be positive in about 40% of cases (I have heard figures ranging from 30 to 70%). Common questions clinically are (1) what determines a SEKG to be positive, (2) what further investigations one could perform if still suspicious about IHD (plus their rationale and mechanisms) and (3) what to do if the patient is not "stressable" (eg. persantin perfusion study).
Posted on Thursday, March 26, 1998 at 10:51 AM
Merck Manual Recommended Reading for Question 3:
ANGINA PECTORIS;Diagnosis
ANGINA PECTORIS;Differential Diagnosis
4. A 75 year old woman comes to the clinic because she has band-like burning pain in the right upper quadrant extending from the epigastrium around to the midline of the back. On physical examination, there is no abdominal tenderness. Findings on ultrasonography of the gallbladder are normal; serum amylase concentration is normal. The most likely diagnosis is
a) acalculous cholecystitis
b) chronic relapsing pancreatitis
c) diverticulitis of the cecum
d) herpes zoster
e) penetrating duodenal ulcer
View Answer D: Herpes zoster
Herpes Zoster is also known as Shingles
H & P
Prodrome of pain and paresthesia in involved dermatome which may simulate pleu7risy, MI, ulcer, or renal colic. The typical rash is localized, unilateral, and does not cross the midline. Grouped vesicles on a pink base form pustules and crusts.
Diagnosis
Positive Tzank Smear demonstrating multinucleated giant cells, viral culture
This diagnosis is the same as for varicella
Disease Severity
Pain is more severe in elderly patients
disease is more severe in immuocompromised = skin necrosis and scarring, postherapetic neuralgia, dissemination.
Concept and Application
Infection is a recrudescence of latent infection with varicella-zoster infection, passed to the skin and mucosa by sensory nerves from dorsal ganglia
cellular immunity is more important in host resistnace (increased incidence of infection in patients with HIV or immunocompromise)
Management
Topical
Cool compresses
Calamine Lotion
Antibiotics for secondary bacterial infection
Systemic
Acyclovir 800 mg 5 times/d for 1 week
Famciclovir 500 mg 3 times/d, analgesics
Postherpetic Neuralgia
Topical capsaicin cream (Zostrix)
Merck Manual Recommended Reading for Question 4:
HERPES ZOSTER
ACUTE CHOLECYSTITIS
ABDOMINAL PAIN;Diagnosis
THE MERCK MANUAL - PEPTIC ULCER;Diagnosis and Differential Diagnosis
THE MERCK MANUAL - ACUTE PANCREATITIS;Laboratory Findings and
5. An 18 month-old white infant is brought to the clinic because of pallor and irritability. Her mother says the infant's diet consists almost exculsively of whole milk, approximately 40 oz per day. On physical exam, she has a pulse of 160/min, respirations of 50/min, and normal heart sounds with a grade 2/6 systolic ejection murmur. Her liver is palpable 3 cm below the right costal margin. Laboratory studies show:
Hematocrit 13%
Hemoglobin 3 g/dL
MCV 48 um3
Platelets 400,000/mm3
Reticulocyte count 0.8% (N=0.5-1.5% of red cells)
WBC 12,000/mm3
Following other appropriate studies, the most appropriate management would be to
a) administer oral folate therapy
b) administer parenteral iron therapy
c) administer parenteral vitamin B12 (cyanocobalamin) therapy
d) begin transfusion with packed erythrocytes
e) begin transfusion with whole blood
Back to questions 1-5
6. An 18-year-old woman comes to the clinic because she has missed two menstrual periods. She says she has not been sexually active. The pelvic examination is difficult because she is tense and complains of pain throughout the examination. The most appropriate next step is to
a) arrange pelvic ultrasonography
b) do a urine preganancy test
c) determine serum follicle-stimulating hormone (FSH) and luteinizing hormone (LH) concentrations
d) prescribe medroxyprogesterone therapy, 10 mg orally every day for 10 days
e) reassure the patient that this is normal for her age, but she should return in 3 months if her periods do not resume.
View Answer B: Do a urine pregnancy test
7. A 12 year old girl is referred to the clinic by the school nurse for evaluation of scoliosis. Her scoliosis was detected during a routine screening examination at the school and appears mild (curve less than 10 degrees). She is athletic and is otherwise in good health. During the physical examination, particular attention should be given to:
a) arm length
b) blood pressure
c) body weight
d) cardiac examination
e) stage of pubertal development
View Answer E: Stage of pubertal development
The term scoliosis denotes lateral curvature of the spine, which is always associated with some rotation of the involved vertebrae. Scoliosis is classified by its anatomic location, in either the thoracic or lumbar spine, with rare involvement of the cervical spine. The convexity of the curve is designated right or left. Thus, a right thoracic scoliosis would denote a thoracic curve in which the convexity is to the right; this is the most common type of idiopathic curve. Posterior curvature of the spine (kyphosis) is normal in the thoracic area, although excessive curvature may become pathologic. Anterior curvature is called lordosis and is normal in the lumbar and cervical spines. Idiopathic scoliosis generally begins at about 8 or 10 years of age and progresses during growth. In rare instances, infantile scoliosis may be seen in children 2 years of age or less.
Idiopathic scoliosis is about four or five times more common in girls than in boys. The disorder is usually asymptomatic in the adolescent years, but severe curvature may lead to impairment of pulmonary function in later years. It is important to examine the back of any adolescent coming in for a routine physical examination in order to identify scoliosis early. The examination is performed by having the patient bend forward 90 degrees with the hands joined in the midline. An abnormal finding consists of asymmetry of the height of the ribs or paravertebral muscles on one side, indicating rotation of the trunk associated with lateral curvature.
Diseases that may be associated with scoliosis include neurofibromatosis, Marfan's syndrome, cerebral palsy, muscular dystrophy, poliomyelitis, and myelodysplasia. Neurologic examination should be performed in all children with scoliosis to determine whether these disorders are present.
Five to 7% of cases of scoliosis are due to congenital vertebral anomalies such as a hemivertebral or unilateral vertebral bridge. These curves are more rigid than the more common idiopathic curve (see below) and will often increase with growth, especially during adolescence.
Eighty percent of scoliosis is idiopathic. Since 30% of family members are also affected, siblings of an affected child should be examined.
Idiopathic infantile scoliosis, occurring in children 2-4 years of age, is quite uncommon in the United States; it is more common in Great Britain. If the curvature is less than 30 degrees, the prognosis is excellent, as 70% resolve spontaneously. If the curvature is more than 30 degrees, there may be progression, and the prognosis is therefore guarded.
Postural compensation of the spine may lead to lateral curvature from such causes as unequal length of the lower extremities. Sciatic scoliosis may result from pressure on the spinal cord or roots by infectious processes or herniation of the nucleus pulposus; the underlying cause must be sought. The curvature will resolve as the primary problem is treated.
Treatment of scoliosis depends on curve magnitude, skeletal maturity, and risk of progression. Curvatures of less than 20 degrees usually do not require treatment unless they show progression
8. A 19 year old African-American college student comes to the student health center because of marked fatigue. Physical examination shows a temperature of 38.3 C (101.0 F) and striking pallor of skin, nail beds and conjunctivae. There are petechial hemorrhages in the skin of his legs. A soft blowing systolic murmur is present over the precordium. No other abnormalities are present. The most appropriate study at this time is
a) complete blood count
b) determination of bleeding and clotting time
c) examination of bone marrow aspirate
d) hemoglobin electrophoresis
e) serological testing for infectious mononucleosis
View Answer A: complete blood count
I agree with the anonymous poster in the newsgroup that the CBC is to characterize the degree of the patient's anemia (and platelet count) in this case. However, this patient appears to have a platelet disorder rather than hemorragic fever.
Excerpted from the Merk Manual with permission:
Platelet disorder:
Thrombocytopenia may stem from failure of platelet production, splenic sequestration of platelets, increased platelet destruction or utilization, or dilution of platelets. Regardless of cause, severe thrombocytopenia often results in a typical pattern of bleeding: multiple petechiae in the skin, often most evident on the lower legs; scattered small ecchymoses at sites of minor trauma; mucosal bleeding (epistaxis; GI and GU tracts, and vaginal bleeding); and excessive bleeding after surgery. Heavy GI bleeding and bleeding into the CNS may be life-threatening manifestations of thrombocytopenic bleeding. However, thrombocytopenia does not cause massive bleeding into tissues or hemarthroses, such as may occur in bleeding secondary to plasma coagulation factor deficiencies (eg, hemophilia).
A thorough drug history must be taken to rule out exposure to drugs known to cause increased platelet destruction in sensitive patients. About 5% of those receiving heparin may develop thrombocytopenia (see HEPARIN- INDUCED THROMBOCYTOPENIA, below). Thus, it is important to establish whether a patient is receiving heparin. Since this is neither dose- nor route-dependent, it can occur even with the mere use of very low doses as with heparin flushes to keep IV or arterial lines open. Other drugs that less commonly induce thrombocytopenia in sensitive individuals include quinidine, sulfa preparations, oral antidiabetic agents, gold salts, and rifampin. Because patients infected with the human immunodeficiency virus (HIV) may present with an isolated severe thrombocytopenia otherwise indistinguishable clinically from idiopathic thrombocytopenic purpura (ITP, see below), risk factors and history of other symptoms of HIV infection should be elicited. Other important points in a history may be a blood transfusion within 10 days (possible post transfusion purpura), significant alcohol consumption (possible alcohol- induced thrombocytopenia), and symptoms (eg, arthralgia, Raynaud's phenomena, unexplained fever) suggestive of an underlying immunologic disease.
Differential diagnosis: Presence or absence of fever is an important point; it is usually present in thrombocytopenia secondary to infection or active SLE and in thrombotic thrombocytopenic purpura (TTP), but absent in ITP and in drug-related thrombocytopenias. Size of the spleen on physical examination is a second important point. The spleen is not palpably enlarged in most thrombocytopenias caused by increased platelet destruction (eg, ITP, drug- related immune thrombocytopenias, TTP), whereas it will be palpably enlarged in patients with thrombocytopenia secondary to splenic sequestration of platelets, and often in patients with thrombocytopenia secondary to a lymphoma or a myeloproliferative disorder.
Laboratory findings: The peripheral blood cell count is a key examination not only for establishing the presence and severity of thrombocytopenia, but also for detecting clues to its cause. Platelet size should be noted; an increased proportion of large platelets (determined by scanning the blood smear or by measuring mean platelet volume [MPV] with an electronic blood counter) suggests compensatory increased platelet production. It is often found in thrombocytopenias secondary to increased platelet destruction or utilization. Since the bleeding time will be substantially prolonged in severe thrombocytopenia of any cause, it adds no information, but may provide useful information in the patient with a moderate thrombocytopenia (eg, a platelet count of 50,000/uL). A very long bleeding time suggests that the process causing the thrombocytopenia (eg, coating of platelets with antibody) has also impaired the function of circulating platelets. Other screening tests of hemostasis (see above) will be normal unless the thrombocytopenia is associated with another condition affecting hemostasis (eg, liver disease or DIC). Bone marrow aspiration provides the number and appearance of megakaryocytes, and confirmation of the impression gained from the peripheral blood smear of the presence or absence of disease causing marrow failure (eg, leukemia). Measurement of platelet-associated IgG may also be of value in selected patients. Regardless of the history of risk factors for HIV infection, serologic tests should be done with the patient's consent. If a patient receiving heparin becomes thrombocytopenic, a test for heparin-induced platelet aggregation or for heparin-dependent platelet release (of serotonin or ATP) should be carried out.
Treatment of thrombocytopenia varies with its cause and requires rapid identification of the cause and correction if possible (eg, discontinuing heparin in heparin-associated thrombocytopenia, recognizing and treating an infection causing gram-negative endotoxemia, inducing a remission in a patient with acute leukemia). When thrombocytopenia is secondary to decreased production, giving platelet concentrates will usually raise the platelet count for 2 to 3 days. Platelet concentrates should be used prophylactically with discretion, since their effectiveness may be lost with repeated use owing to the development of platelet alloantibodies. If rapid correction of bone marrow failure is not expected, platelet transfusions are often reserved for management of an active bleeding episode. Platelet concentrates should rarely be used prophylactically in patients with thrombocytopenia secondary to increased platelet consumption (eg, in ITP), since they will usually be cleared from the circulation within 1 to several hours. However, if a patient with ITP is experiencing serious mucosal or CNS bleeding (a medical emergency) then high-dose immune globulin is given IV followed by platelet transfusions. The platelet concentrates may be given continuously (1 to 2 u./h) or in larger amounts every few hours (eg, 6 to 8 u. q 4 to 6 h). Platelet concentrates should not be given (unless death from bleeding would otherwise ensue) in 2 thrombocytopenic disorders due to increased platelet consumption: heparin-induced thrombocytopenia and TTP. In these disorders transfused platelets may be incorporated into platelet-fibrin thrombi and thus trigger a serious thrombotic event.
HEMORRHAGIC FEVER WITH RENAL SYNDROME (HFRS)
(Korean Hemorrhagic Fever; Epidemic Nephrosonephritis; Nephropathia Epidemica)
An acute infection caused by species of Hantavirus, transmitted to man from rodents and characterized by renal involvement (nephritis) and hemorrhage.
Etiology and Epidemiology
The genus Hantavirus consists of at least 4 species: Hantaan virus (Korean hemorrhagic fever), Seoul virus (a milder form of Korean hemorrhagic fever), Puumala virus (nephropathia epidemica), and Prospect Hill virus (isolated from meadow voles in Maryland and not associated with human disease). Hantaviruses have been isolated from rodents throughout the world; 42% of Norway rats in Baltimore tested between 1980 and 1986 had antibodies to Hantaan virus. An increasing number of naturally acquired and laboratory- associated infections are being reported in Europe. The virus is present in the urine, feces, and saliva of various rodents, including field and laboratory mice, rats, and voles. Transmission from rodent to rodent is primarily respiratory, with transmission to humans through inhalation of infectious aerosols from rodent excreta. There is no evidence of human-to-human transmission.
Symptoms, Signs, and Laboratory Findings
A milder form of this disease was diagnosed in Scandinavia as nephropathia epidemica and is characterized by sudden onset of high fever, headache, backache, and abdominal pain. On the 3rd or 4th day, conjunctival hemorrhages, palatine petechiae, and a truncal petechial rash may appear. About 20% of patients develop a toxic condition and become mentally obtunded. Oliguria and azotemia develop concomitantly with the hemorrhagic manifestations. Urinalysis reveals proteinuria, hematuria, and pyuria. The rash subsides in about 3 days; the patient develops polyuria and recovers over several weeks.
In the more severe eastern form of HFRS, the clinical course may be divided into 5 phases: febrile, hypotensive, oliguric, diuretic, and convalescent. The incubation period is 7 to 36 days, usually 10 to 25 days. The severity of illness varies considerably; about 65% of cases are mild, while 10 to 15% are severe. The onset is usually abrupt (febrile phase) with chills, fever, backache, abdominal pain, and myalgia. The fever peaks on the 3rd or 4th day. There is a relative bradycardia. One of the most typical early findings is a diffuse reddening of the face, resembling a sunburn. Dermatographism can be demonstrated in > 90% of patients. Petechiae develop on the 3rd to 5th day, initially on the palate, then at pressure areas such as the axillary folds. Conjunctival hemorrhages appear at about the same time. Laboratory findings are unremarkable except for albuminuria, which appears between the 2nd and 5th day. The urinary sediment reveals hematuria and RBC and WBC casts. About the 5th day, shock or hypotension may occur (hypotensive phase); in mild cases, the fall in BP is only transient. At this stage, the Hct increases and marked proteinuria, leukocytosis, and thrombocytopenia develop. About the 8th day, BP returns to normal but oliguria develops (oliguric phase). BUN levels increase rapidly, and hemorrhagic manifestations become more prominent. Diuresis (diuretic phase) occurs about the 11th day, and CNS and pulmonary complications may be seen. The convalescent phase lasts 3 to 6 wk.
Prognosis and Treatment
Overall fatality in HFRS is 6 to 15%. Residual renal dysfunction is uncommon in Korea but may be more common in Europe.
Treatment involves meticulous supportive care. Renal dialysis may be required. Experimental trials suggest that ribavirin IV in dosage regimens similar to those used in Lassa fever may be beneficial.
9. A 17 year old high school senior comes to the clinic because of pain during her menses for the past 2 years. She describes the pain as crampy, felt in the lower abdomen and radiating to the back. She says it is most severe the second day of the flow and subsides thereafter. Her medical history shows that menarche was at age 14 years. Physical examination is normal. The most appropriate next step is to
a) begin a therapeutic trial of aspirin
b) begin a therapeutic trial of ibuprofen
c) determine serum CA-125 concentration
d) do diagnostic laparoscopy
e) do a dilatation and curettage
View Answer B: Begin a therapeutic trial of ibuprofen
From Chris:
Dysmenorrhea, aka "painful menstruation" is the chief complaint of this
17 y/o pt. She experiences a typically
lower abdominal pain consistently on the second day of menstruation, and
apparently at no other interval. The
pain irradiation to the back is probably a "red herring" as nothing else
in the Hx suggest otherwise.
Other remote possibilites on a differential dx of dysmenorrhea
(secondary):
* chronic PID - pt not sexually acive (?)
* intrauterine device
* leiomyomas - pt is too young
* endometriosis - " "
- interestingly enough this pt's menarche was 2 years ago, primary
dysmenorrhea usually presents 2 years after
the onset of menses.
*******************************
An NSAID trial could prove beneficial since the cause for this type of
"painful menst" is thought to be secondary
to Pg-induced myometrial contractions.
Estrogen therapy is an alternative, although beginning Ibuprofen a few
days before the anticipated menses can often help.
******************************
If the pt were older the endometriosis (a known cause of 2ary
dysmenorrhea) would have been given greater consideration, and
particularly if she had a Hx of "infertility."
- CA-125 is often a "false +" in pre-menopausal women !!
10. A 21 year old man comes to the clinic because he has become increasingly short of breath and has had a cough for the past week. He appears dyspneic and has a temperature of 38.3 C (101.0 F). On physical examination he has bibasilar rales and genearlized lymphadenopathy (1 to 2 cm). Rectal examination shows multiple perianal contusions and a small amount of blod oozing from the anal orifice. A chest x-ray film shows bilateral patchy alveolar infiltrates. The most appropriate course of action is to order blood tests and to
a) admit him to the hospital and begin administration of trimethoprim-sulfamethoxazole, intravenously
b) admit him to the hospital and begin administratio nof penicillin and gentamicin, intravenously
c) begin adminstration of erythromycin, orally, and see him again the next day
d) prescribe isoniazin and rifampin, orally
e) recommend aspirin, fluids and rest at home
View Answer A: admit, start on tmp-sulfa IV.
Explanation courtesy of Chris of the Newsgroup.
- A 21 y/o pt with fever, SOB, cough (non-productive ?), and lymphadenopathy initially suggests Infect. Mono, although we are not informed if there is splenomegaly.
- bibasilar rales indicate a pneumonic process, maybe asociated with the other findings. Viral ? EBV ?
- by virtue of the DRExam, we can assume that this patient is a practicing homosexual. Now the differential dx should include R/O Hiv(+), AIDS, and PCP,the latter which could account for the fever, increasing SOB & cough, although the CXR is not typical of the diffuse INTERSTITIAL infiltrates caused by P. carinii.
If you consider AIDS on the list of dx, then the lymphadenopathy could be 2ndary to lymphoma, syphilis etc.
*********************
As far as mgmt is concerned, this pt must be assumed to have PCP and must receive Bactrim. (A
Click here for questions 6-10
11. A 29 year old Italian-American woman comes to the office for her first prenatal visit. Her last menstrual period was 16 weeks ago. This is her first pregnancy; her family history is unremarkable. She has heard that people of Mediterranean ancestry are at risk for carrying a gene for ß-thalassemia. She asks to be tested for this. The most appropriate initial diagnostic study is
a) complete blood cell count with red cell indices
b) hemoglobin electrophoresis
c) red cell osmotic fragility test
d) restriction-fragment length polymorphism (RFLP) analysis of her ß-globin gene
e) reticulocyte count
View Answer A: complete blood count with red cell indicees
Erythrocytes of the beta-thalassemia heterozygote have an MCV of 55 to 80 fl and a corresponding reduction in MCH. The RDW is normal in contrast to iron deficiency anemia, in which it is high. People who are silent carriers can have a normal MCV value. The red cell count is often elevated and the blood film commonly shows target cells and basophilic stippling (Plate III-4, M). Reticulocyte counts may be elevated (2% to 3%), but this is an inconsistent finding. Detection of most heterozygotes is simplified by the presence of an elevated HbA2 level (4% to 6%), which is most accurately measured by column chromatography. HbF level may be slightly increased (1% to 3%). In delta-beta-thalassemia carriers, the HbA2 level is normal or reduced, and the HbF concentration is increased (5% to 20%).
Homozygotes are severely anemic with hemoglobin levels of less than 5 g/dl in the absence of transfusion. MCV and MCH are reduced, and the reticulocyte count strikingly elevated. The blood film findings are characterized by nucleated red cells, Pappenheimer and Howell-Jolly bodies, marked anisocytosis, poikilocytosis, and polychromatophilia. The bone marrow is hypercellular with marked erythroid hyperplasia and increased iron stores. Heinz bodies can be demonstrated by special staining methods (Plate III-4, P). Fetal hemoglobin is the major hemoglobin component, with absent or very reduced levels of HbA. The HbA2 level shows considerable variation. Other indicators of chronic hemolysis are present, such as unconjugated hyperbilirubinemia, elevated LDH level, and decreased haptoglobin. Radiography of the skull may show the "hair on end" appearance of an enlarged diploic space, and other bones may appear osteoporotic.
Differential diagnosis
The heterozygous beta thalassemias may be confused with iron deficiency and other microcytic anemias. There are few disorders that may be confused with the severe homozygous beta thalassemias. Improperly managed patients with serious growth retardation, impaired nutrition, and marked hepatosplenomegaly superficially resemble individuals with advanced cirrhosis of the liver or malignancy.
Treatment
Heterozygous beta thalassemias require only recognition, so that iron is not injudiciously administered, and carriers can be offered counseling. Screening programs, based on the detection of microcytosis and presence of elevated HbA2 levels, are practical in groups with a high disease prevalence. When a family is at risk for having homozygous offspring, prenatal diagnosis is possible. In parts of Greece, Italy, and Cyprus, screening, counseling, and prenatal diagnosis have led to a nearly 100% reduction in the numbers of homozygotes born.
Intensive transfusion therapy and chelation of excessive iron have improved the management of severe disease. When transfusion is started very early in life and the hemoglobin levels are kept at 9 to 10 g/dl, erythropoiesis is suppressed, marrow expansion does not occur, severe hemolysis is not present, and growth and development are near normal. Besides the usual complications of transfusion, such as alloimmunization and transmission of retroviral infection, the iron burden, deposited in tissues as a result of the destruction of transfused blood, must be removed by chelation to prevent the development of transfusion-induced hemochromatosis. Desferrioxamine (Desferal), a chelating agent, is given by prolonged subcutaneous or intravenous infusion, 8 to 12 hours nightly, 5 to 6 days weekly, at doses of 2 to 6 g/day, using a portable infusion pump. The regimen must be tailored to each individual as the amount of iron excreted varies. Although optimum chelation therapy can induce negative iron balance, the ultimate effects of this treatment are not yet known. When treatment is started after significant iron accumulates, the cardiomyopathy may not always be reversible and is a leading cause of death, although intense chelation may reduce the prevalence of arrhythmias and congestive failure. Ideally, chelation should be started in young children before the acquisition of excessive iron stores. Low doses of vitamin C may increase the excretion of iron by desferrioxamine and can be used in vitamin C depleted individuals while they are receiving chelation treatment. An effective oral chelating agent that provides relief from the arduous regimen of subcutaneous infusion may soon be available.
Splenectomy may be performed when the red cell survival shortens. This reduces the excessive red cell destruction and cytopenias of hypersplenism and lengthens the interval between transfusions. Severe postsplenectomy infection is a risk that must be weighed and argues for delaying surgery as long as possible. Polyvalent pneumococcal, Haemophilus influenzae and Neisseria meningitidis vaccine should be given before surgery and prophylactic penicillin afterward.
Bone marrow transplantation has been employed in severe beta thalassemia and considerable experience has been gained in Italian centers. It is the sole way to eradicate the disease. However, the best candidates are the youngest children, as older, more heavily transfused patients are less likely to become engrafted and have higher morbidity and mortality. Because transfusion and chelation can allow normal development and a decent quality of life for many years, and because bone marrow transplantation still has appreciable short-term mortality, the decision to recommend this therapy has been very difficult. However, in children who have little or no liver disease as a result of efficient chelation, transplantation using haploidentical donors results in a disease-free survival rate of 95%. If these results are replicable, then early transplantation may be the most efficacious and cost-effective method of treatment and free the patient from the lifelong burden of parenteral chelation therapy. If the promise of an effective oral chelating drug is realized, the arguments regarding early transplantation may have to be reconsidered.
Preliminary studies have suggested that hydroxyurea may increase the level of HbF and raise the hemoglobin level in some individuals with severe beta thalassemia. This therapy may be enhanced by the administration of erythropoietin. These are exciting experimental observations but await further study before their use can be recommended. Further over the horizon are other HbF-inducing agents, such as butyrate analogs, and means of altering the genetic defects of thalassemia by gene therapy.
12. An 84 year old woman is brought to the office by her daughter, who is your patient. The mother has just moved in whith the family because she can no longer take care for herself due to progressive, long-standing dementia. The daughter hopes you will help take care of her mother. On physical examination the mother has no evidence of any other chronic disease. She does not respond to your words or to the physical examination. You notice that she smells of urine. On examination of the pelvis there is a diffuse erythematous rash extending over the prineum to the medial thighs bilaterally. You suspect the rash relates to urinary incontinence. The daughter is present at the mother's examination. The best opening remark to the daughter is:
a) "You should take better care of your mother"
b) "How long have you left your mother in this condition?"
c) "Your mother needs to wear diapers"
d) "This rash should respond to cleansing with mild soap and drying with a clean towel three times a day"
e) "This is a rash caused by urine. My nurse wll insert a Foley catheter"
View Answer D: "This rash should respond to cleansing..."
13. A 67 year old woman, who is a regular patient, calls the office complaining of severe muscle weakness, polyuria and muscle cramps. She began treatment 6 weeks ago with 50 mg of chlorthalidone daily for mild-to-moderate essential hypertension. The most likely explanation for her symptoms is the development of
a) hypokalemia
b) hypomagnesemia
c) hyponatremia
d) metabolic acidosis
e) noninsulin-dependent (tyype II) diabetes mellitus
View Answer A: Hypokalemia
For an explanation of this answer you can go to http://www.studynow.com and visit the section on search drugs (search for chlorthalidone).
Explanation by Chris:
67 y/o female has received 6 weeks of CHLORTHALIDONE (at the appropriate dose of 50mg QD) for her Hypertension, presents with acute/sudden onset ?? of muscle weakness, cramps, and polyuria.
- we are not given the actual period of the onset of symptoms, but the introduction implies that this is a recent occurence.
- chronic use of diuretics certainly causes hypokalemia, but symptoms such as the muscle weakness and cramps experienced by our patients appear at levels less than 2.5mEq.
* Hyponatremia also figures into the list of possible causes, but many patients are asymptomatic even with levels of 130mEq, and when do they do develop the forementioned symptoms it is often accompanied by an altered mental status, this patient seems to be fully alert and oriented relegating this possibility after HypoK+ on the differ dx list.
* Hypomagnasemia is not likely to occur ithis patient (ie. NO hyperalimentation) and she does not present with the typical manifestations of the associated hypocalcemia: fasciculations, Chvostek, and Trousseau. Therefore this lyte disturbance is also not very likely.
* diabetes is a rather remote possibility as this pt seems to have been closely followed as the history suggests with no documentation of any associated findings. A presentation this late in life is highly unusual. We have Not enough evidence to incriminate diabetes.
* metabolic acidosis is also unlikely, as there is no identifiable cause for this complication.
- the polyuria "may" be expected, as some patients admit to "increasing their diuresis" after receiving this class of meds.
*******************************
Hypokalemia is the most probable offender (A).
14. A 71 year old retired publisher comes to the office for her annual health maintenance visit. She is in good health and has no complaints. On pelvic examination she has a 10-cm firm mass in her right adnexa, which has both cystic and solid components on ultrasonography. The most appropriate next step is to
a) aspirate the mass under ultrasonic guidance
b) obtain a carcinoembryonic antigen (CEA) tumor marker
c) reexamine her in 3 months
d) schedule diagnostic laparoscopy
e) schedule exploratory laparotomy
View Answer E: Exploratory laparotomy
From Chris:
71 y/o pt on her annual health exam; asymptmatic. P.E. significant for a
10 cm right adnexal mass, with both cystic-solid components.
*********************
Post-menopausal pt with a large adnexal mass. This ominous finding
demands of us to R/O an ovarian neoplasm as our first and foremost
priority. Nonetheless other causes exist:
- Uterine Leiomyomas (affectionately known as "myomas")
- Colon CA
- Retroperitneal Tumor
- "Full bladder"
- "Feces in colon
Myomas in this pt are ruled out by virtue of (-) U/S findings. The pt is
described as being in "good health," and we can assume in this case that
no weight loss has occured.. therefore if a retroperitonal neo
(Pancreatic CA) that size would most certainly have caused this woman to
be cachetic and symptomatic (ie. jaundice), she's not. Colon Ca, not
likely since again there is no history of weight loss, pain or anemia
(expected of an advanced Right-sided Colon CA). Thus our dx is R/O
Ovarian (malignant) neoplasm.
***********************
There is a general consensus among Gynecologists to remove ALL masses
in postmenopausal women due to a rather relatively "high" frequency of
malignancy. An indication for removal of a suspected ovarian mass is
"persistence of several months" and ">8cm diameter." The answer is (E)
exploratory lap.
***********************
The cystic-solid (loculated) nature of the mass in question points to
the following ovarian tumors as suspects:
Benign and more frequent: mucinous cystadenoma, serous cystadenoma >>
cystic teratoma (aka "dermoid cyst")
Malignant & less frequent: mucinous cystadenoCA, serous adenoCA
***********************
***********************
Clinical Pearl:
- prepubertal female with pelvic mass: R/O germ-cell tumor (50%
malignant), therefore malignant until proven otherwise.
- reproductive age " " ": observe mass for >1 menstrual cycle (ie.
functional follicular cyst vs..)
- postmenopausal " " ": remove all masses.
+ 80% of all Ovarian CAs are benign.
15. A 4 year old boy is brought to the office because he has become unmanageable at his day-care center. You have examined him two other times during the past year because of short stature. At those visits he exhibited some behavior problems which his mother did not set limits. He constantly interrupted situations, seeking his mother's attention. She now reports that during the past few months his fighting, refusal to obey the day-care workers and violations of "time out" have become much worse. He began to attend day-care at 6 weeks of age so that his mother could return to work. Because his parents work long hours, he is often cared for after day-care by any other of several relatives. His father did not finish the ninth grade and now works as a house painter; he is alcohol-dependent. The boy has a 6-month old sister who also attends the same day-care center. Records show his height and weight ar at the 5th percentile, and his growth velocity is normal. There were no complications during the pregnancy with this child and he has not had any significant medical problems. His physical examination today is normal. The most likely cause for this child's worsening behavior is
a) aggressiveness to compensate for a poor self-image cause by short stature
b) attention-deficit/hyperactivity disorder due to inherited factors
c) a reaction to his father's drinking
d) reduction in his mother's attention because of his new sibling
e) a toxic reaction to organic fumes from his father's clothes and work materials
16. A 76 year old woman returns to the office because of aching and weakness in her arms to the point where she cannot lift them to brush her hair. Physical examination shows no muscle tenderness or other evidence of joint disease in the upper extremity. The aching improves when she takes the prescribed nonsteroidal anti-inflammatory drug (NSAID). She also describes localized scalp tenderness over the right parietal area. Physical examination of the scalp shows no lesions. The most appropriate next step would be to
a) increase the dose of the NSAID
b) order determination of erythrocyte sedimentation rate
c) order determination of rheumatoid factor
d) order x-ray films of the cervical spine
e) refer her for psyciatric counseling
View Answer B: Order ESR
Explanation by Chris:
76 y/o woman presents with "aching" & "weakness" in her arms...
apparently with difficulty raising small objects and perform light
exercise. Pt reports "scalp tenderness." Admits to improvement with
NSAIDs. PMHx is negative. P.E. is apparently unremarkable.
- We should ask for how long as this complaint been present ?
- Its onset ? Duration (constant vs. occasional) ? Weight loss ? H/A ?
************************************
Entities which should arouse our suspicion:
- Rheumatoid Arthritis ??
- Polymialgia Rheumatica
- Giant Cell Arteritis (Temporal Arteritis)
- Polymiositis
************************************
We will first R/O the most common causes first...
- R/A: no joint pain, limitation is noted, and since the PE is
apparently negative, we assume that no nodules our observed as are other
manifestations of R/A -- essentially ruled out.
- PM: the complete PE (including neuro exam) would have detected any
proximal muscle weakness, any tenderness or muscle atrophy...none is
documented, and no skin lesions (ie. knuckles) described... just in case
an associated dermatomyositis were to be expressing itself, thus PE is
relegated to the bottom of the Diff Dx list.
- PMR-GCA: can manifest itself with weakness, usually with the shoulder
girdle being most affected (A point in favor), improvement with NSAIDs
(A point in favor), and scalp tenderness (A point in favor)... WE ARE
OBLIGED TO INTERROGATE FOR H/A AND JAW CLAUDICATION (ie. during chewing)
..but MOST IMPORTANTLY... LOSS OF VISON !!!
$ BTW Some researches have postulated that PMR and GCA are the same
disease process, but different stages.
*************************************
We now seem to have our culprit... PMR - GCA. Therefore (B) "ESR" is
the best answer, although I believe that we would all agree to begin a
course of prednisone stat before the patho report of an obligated
temporal artery biopsy were available.
- Chris
17. (17-18) A 38 year old homemaker and mother of four children (ages 5-12 years) has been coming to you for tension headaches that have not improved much with trials of several appropriate medications. She has been married to a policeman for the past 6 years. You ask if she has been under extra stress, and she begins to cry. You notice bruises on her arms. On further questioning, you learn that her husband hits her whenever he is drunk, which is at least 2 nights per week. She syas, "he is nice...a good husband when he's sober. But when he drinks, oh he's awful! He accuses me of cheating on him. Last night he said he would kill me if I try to leave." Her husband is also a patient of yours.
17. The most appropriate intervention would be to
a) advise her to leave her home with her children and move in with her relatives
b) contact her husband's supervisor to discuss recent stress levels on the job
c) gather more information while remaining neutral, since both the husband and wife are your patients
d) refer her to a battered women's program
e) seek a restraining order against her husband on her behalf
View Answer d: Refer her to a battered women's program
18. The most vital question to ask at this time is:
a) "Do you think this might be causing your headaches?"
b) "Has your husband also lost his temper with any of the children?"
c) "Have you been drinking at the time of the fights?"
d) "Have you or your husband been receiving any kind of counseling?"
e) "Why have you stayed in this marriage?"
View Answer B: Has your husband lost his tember with any of the children
19. This question requires viewing an x-ray; thus it will be skipped for now.
20. (20-21) A 27 year old man comes to the office because of a 1-week history of right knee pain. He says he has an exercise routine that includes jogging 3 miles a day and that the pain in his knee worsens during his run. On physical examination his gait appears to be normal. Examination of the knee reveals tenderness and fullness over the medial collateral ligament.
20. On physical examination there is most likely to be
a) increased anterior laxity with anterior pressure on the tibia
b) increased posterior laxity with posterior pressure on the tibia
c) a painful clicking sensation with inward rotation of the foot and extension of the knee
d) pain during forced abduction of the leg below the knee
e) pain during internal and external rotation of the tibia while compressing it against the femur
View Answer D: Pain during forced abduction of the leg below the knee
21. The most accurate statement concerning this patient's condition is that he will need
a) to choose a different type of activity for his exercise program
b) initial treatment with rest, ice packs and isometric exercises
c) treatment with knee immobilizaton and crutches
d) referral for an orthotic device
e) referral for arthroscopy
22. A 69 year old Chinese-American man with diabetes mellitus had a myocardial infarction 2 years ago. He has had exertional angina since then and has been taking propranolol. During the past few days he has had one episode of pain at rest, two episodes postprandially and one at night. The electrocardiogram is unchanged. The preferred treatment would consist of
a) admitting him immediately for cardiac monitoring and adjustment of therapy
b) admitting him immediately for coronary artery bypass surgery
c) decreasing the dosage of propranolol and adding nitrates and salicylate
d) increasing the dosage of propranolol and having him return in 1 week
e) resting from work, sedation at night and digitalization
View Answer A: admitting him immediate for cardiac monitoring and adjustment of therapy
Chis Responds:
69 y/o pt with a PMH significant for past MI 2 years ago and exertional
angina thereafter. Consults for:
* increase in number of episodes
* apparition of angina at rest.
*******************************************
This pt's course has rapidly accelerated within the past few days and
can now be considered to have "Unstable Angina." By all means keep the
Beta-Blockers. Its well-known that these meds decrease the risk for
future cardiac events.
*******************Answer is (A)**********************
He must first be admitted to document any ischemic changes, and in what
area(s)/territories they are taking place.
******************************************************
I would then add nitrates to this pt's anti-anginal regimen, and if he's
not receiving ASA (300mg) add that as well... but taking into his
history of known MI, I might be hesistant to wait for another
potentially lethal anginal episode and begin treatment ASAP.
In light of his rapidly progressive course I would like to cath this
fellow, and keep the CABG as a later option depending on how many
vessels are compromised.
* Pearl: if only 1-2 vessels is severely affected then PTCA
" > 2 " then CABG.
Taken from the EAST trial at Emory U., Atlanta.
23. A 38 year old woman who is single mother of two small children comes to the office saying that she feels "halfway tired all the time." Her physical examination is unremarkable and unchanged from 1 year ago. Toward the end of the visit she says anxiously, "My children just don't listen. They make me so angry that I feel out of control sometimes." She pauses. "Yesterday my 7 year old daughter talked back to me and I slapped her in the face." Her eyes fill with tears. The most accurate statement concerning this patient is that she
a) should be reported to child abuse authorities
b) was clearly a victim of child abuse herself
c) would benefit from antidepressant medication
d) would benefit from family counseling
e) would exhibit better self-control if she were married
View Answer D: would benefit from family counseling
24. A woman telephones because her 7 month old infant is irritable and has a temperature of 39.6 C (103.2 F) with persistent vomiting. Upon questioning, she reports that the infant's neck is supple. Further diagnostic work-up should be based on the need to rule out
a) bacterial meningitis
b) bacterial pneumonia
c) hamartoma of the hypothalamus
d) herpetic encephalitis
e) viral respiratory infection
View Answer A: bacterial meningitis
Chis Responds:
7 m/o infant's mother consults for:
- Fever (39.6 C)
- irritability and vomiting
******************************
This ominous triad should obligate the MD who first sees this child to
R/O Meningitis first and foremost since this is treatable disease, and
the implications of a delayed diagnosis are grave. (A)
According to the baby's age: hemphilus influenze is a prime suspect as
the irrepresable pneumococcus and meningococcus are less frequent in
this age.
Why not ask "Mom" if junior has had fever prior to the present syndrome
? If the pt was older I would ask for "earaches" too.
Pearl: Otitis media + meningitis --> R/O Hemophilus Influenzae.
As far as a PE goes, an otoscopy in an irritable infant is very
difficult and often poorly done, but it can provide an important clue as
to the etiology of the meningitis. In any case an L.P. is warrented and
will ultimately reveal the culprit's identity.
The baby's fontanelle might be bulging, but outright signs of meningism
(ie. nucal rigidity) are infrequently observed in infants.
Ceftriaxone is the abx of choice.
****************************************
Why the other aren't:
- encephalitis: no signs of focalization &/or convulsions (can occur in
bacterial meningitis as well)
- Viral URI: no cough, rinorrhea are documented
- pneumonia: no respiratory distress noted
- hamartoma of the hypo: ???
25. (25-26) Earlier today, you examined a 16 year old boy who came to the office for a school physical examination. He had no complaints or medical problems. He said he is sexually active, has had three different sex partners and that he "sometimes" uses condoms. He had no complaints of dysuria or penile discharge. You know that he would be reluctant to consent to evaluation for asymptomatic urethritis with urethral swabs because of fear of discomfort. In trying to determine how to screen for this prevalent problem, you recall a recent study that compard a new urethritis screening test -- the first part voided urine (FPV) -- to the "gold standard' of urethral culture. In this study, 50 asymptomatic male adolescents provided the first 10 mL of a voided urine specimen (FPV), and urethral swabs were taken for culture of Chlamydia trachomatis and Neisseria gonorrhoeae,. The FPV specimens were spun down, and the sediment was examined microscopically under high power. Twenty-one of 23 (91%) subjects whose FPV showed more than 10 WBC/hpf had positive urethral culture for C. trachomatis or N. gonorrhoeae compared with only 1 of 27 (4%) FPV negative subjects with a positive culture.
25. The most accurate statement about the data is:
a) The FPV is not a helpful screening test because its sensitivity depends on the frequency of urethritis
b) The FPV is not a useful screening test because of its low positive predicitive value
c) No conclusions can be drawn from the data because the samble size is insufficient
d) The sensitivity of the FPV in identifying culture positive urethritis is greater than 90%
e) The specificty of the FPV in identifying patients who do not have urethritis is less than 90%
View Answer D:
26. For a variety of reasons you decide not to institute the FPV as a screening test in your practice. In coming to this decision, you have realized that the most important factor contributing to the positive predictive value of the FPV is the
a) correlation coefficient
b) incidence of urethritis in your patient practice
c) lack of reproducibility
d) prevalence of urethritis in your patient practice
e) reliability factor of the test
View Answer D:
27. A 45 year old man comes to the office for a follow up visit. He has a history of low back pain following a lifting accident at work 3 years ago. Until now his pain has been confined to the lumbosacral region, and he has had no numbness or presthesia in his lower extremities. Today he reports a sensation of pain shooting down the posterolateral aspect of his left thigh, extending medially to his left great toe. The pain is made worse by coughing. The patient's history suggests
a) actue muscle strain
b) chronic lumboscral strain
c) degenerative lumbosacral arthritis
d) intervertebral disc herniation
e) spinal stenosis
View Answer D:
Acute lumbar disk herniation, rupture, or extrusion represents an acute episode in a chronic degenerative process. Patients may have a history of chronic episodic low back pain.
Diagnosis
Pain usually begins abruptly, often with trivial trauma such as sneezing. The pain is often described as stabbing or shooting, worse with sneezing or coughing, and often incapacitatingly severe. Radiation in the distribution of the sciatic nerve is common. The physical findings are similar to those of degenerative disk disease, with the addition of severe paravertebral muscle spasm. Sciatic stretch tests may be positive. Neurologic function, including sensation and deep tendon reflexes, is intact. X-rays and the results of laboratory studies are usually normal.
Treatment & Disposition
Acute lumbar disk herniation usually requires complete bed rest and narcotic analgesics (for the first day or so). Additional measures are as described for chronic degenerative disk disease, above (ie, aspirin, nonsteroidal anti-inflammatory agents, muscle relaxants). Unless ideal support is available at home, the patient requires hospitalization. Bed rest is frequently required for 3-4 weeks, although most patients are significantly improved within 2 weeks.
28. A 67 year old retired carpenter who has been you patient for many years calls the office to complain of a new symptom. He says that when he walks fast or wlaks uphill, usually while playing golf, he has pain in his left calf that disappears with rest. He is overweight, he smokes cigarettes, and he drinks one beer on weekdays and two six-packs on the weekend. You have been treating him with lovastatin for a slightly elevated serum cholesterol concentration. He has never been able to follow your prescribed diet very well. You can tell this patient that the most likely reversible factor related to his pain is his
a) cigarette smoking
b) intake of saturated fats in his diet
c) use of alcohol
d) use of verapamil
e) weight
View Answer A:
Explanation by Chris:
67 y/o pt with PMH significant for obesity and hypercholesterolemia,
smoking presents with recent acute onset of unilateral calf pain while
making a slight - medium effort walking, that resolves spontaneously
with rest.
***********************
Dx: Pveripheral Vascular Disease.
***********************
Risk Factors:
- Diabetes Mellitus
- Hypercholesterolemia
- Smoking
***********************
We are not informed of any PE findings, such as skin discoloration on
the affected extremity, femoral-popliteal-pdeial pulses, bruits, pallor
of extremity when elevated etc..A treadmill test might be helpful to
document first hand the condition, and a Doppler-Duplex study as well,
although this pt may require an invasive study (ie. angiography) to
determine the extent of atherosclerotic compromise. If severe he may
ultimately be subjected to a SRV or PTA.
Tx: Cessation of smoking, exercise therapy, improve lipid profile and
Trental (pentoxiphylline).
Px: Only 50% pts have this condition stabilize or improve. 50% have
coexistent CAD.
Chris
29-30. A 17 year old boy is brought to the office by his mother who says that he has been increasingly withdrawn and preoccupied for several weeks. He has been sleeping poorly nad has refused to leave the house for the past week because he believes he is being followed. When his father insisted he attend school this morning, the patient threatened him with a knife. The patient is sweating, has dialated pupils and is obviously fearful.
29. Rapport with this patient can be best established by asking:
a) "Are you hearing voices?"
b) "Do you have a special mission to accomplish?"
c) "Do you think you are being persecuted?"
d) "How do you feel others are treating you?"
e) "Who do you think is following you?"
View Answer D:
30. After admission to the hospital, the most appropriate first intervention is to
a) administer haoloperidol
b) arrange a conference with the family
c) order CT scan of the head
d) order toxicologic screening of the urine
e) prescribe diazepam therapy, intramuscularly
31. A 50 year old African American man with severe chronic obstructive pulmonary disease returns to the office following a recent evaluation for possible lung transplantation to be done in another city. He says he has been considered a suitable candidate in all respcts, but was rejected by the transplant program when a random urine screen was positive for a nicotine metabolite. He had previously told you that he had stopped smoking 3 years ago. He stands by this and is at a loss to explai