10-17-2007, 08:09 PM
The correct answer is C. This patient most likely has Osgood-Schlatter disease. The typical patient is a physically active pubescent boy who has pain and swelling over the tibial tuberosity. The pain is exacerbated by physical activity. It is caused by apophysitis, (inflammation of the tibial tuberosity), and cartilage detachment. Diagnosis is made by history and tibial tuberosity tenderness. Treatment is the reduction of physical activity.
"Growing pains", (choice A) are usually characterized by deep, severe, bilateral, diffuse pains that are worse at night. There is no associated limp.
Legg-Calve-Perthes disease (choice B), avascular necrosis of the femoral head, is characterized by hip and knee pain, a limp, and decreased range of motion. It usually affects boys between 4 to 8 years of age. Casting and surgery are treatment options.
Osteosarcoma (choice D), is the most common malignant bone tumor in kids. It occurs in the metaphyses of long bones, and presents with pain, swelling, and a palpable mass. X-rays show a lytic lesion with a "sunburst" pattern. Treatment is surgery.
Slipped Capital Femoral Epiphysis (choice E), is a disorder of overweight boys that is caused by a displacement of the femoral head from the femoral neck. There is knee or thigh pain, and a limp. Treatment is immediate surgical fixation
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The correct answer is D. The principle of individual autonomy is central to medicine. The only exceptions are if the patient has no clearly expressed wishes documented and is unable to make a decision or if the patient is deemed incompetent to make a decision. This patient is clearly competent to refuse treatment despite the wishes of his physician or neighbor. It is important to make the consequences of his decision clear to the patient before discharge and to tell him that he should return immediately should he change his mind.
Hospital care with or without intravenous antibiotics (choices A and B) is inappropriate as this patient is refusing hospital care.
This patient is clearly competent to refuse treatment, so he should not be admitted to the psychiatry ward (choice C) or given antidepressant therapy (choice F).
Consultation with an attorney (choice E) is not necessary as the patient is clearly competent to refuse medical care.
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A 39-year-old woman comes to the office for a periodic health maintenance examination. You have been treating her for anorexia nervosa for the past 15 years. She has required 4 hospitalizations during this time. She tells you that she is "doing as well as can be expected" now and that she has a new boyfriend who is very helpful. She is 157 cm (5 ft 2 in) tall and weighs 41 kg (90 lb). She admits that she still does not have a menstrual period. Her temperature is 36.7 C (98.0 F), blood pressure is 100/70 mm Hg, and her pulse is 55/min. Physical examination shows lanugo, dry, scaly skin, yellow discoloration of the palms, and pharyngeal abrasions. At this time the most correct statement is:
A. Electrocardiography will show shortened QT intervals
B. Fluoxetine is not effective in reducing binge eating and purging episodes
C. Her immune function is seriously affected and she is at risk for severe infections
D. Laboratory studies will show hyperkalemia
E. She is at an increased risk for developing osteoporosis
The correct answer is D. This patient is presenting with signs and symptoms of temporal arteritis, also known as giant cell arteritis. This disease is caused by inflammation of the large vessels off of the aortic arch, most commonly manifesting in the temporal artery. Biopsy will show mononuclear and giant multinucleated cells in the intima and media of the vessel. Classic symptoms are new onset temporal headaches in a patient over 60 years of age, jaw claudication as he describes, and an ESR that is markedly elevated. Patients often have pain to palpation over the temporal artery itself. There is also a high association with polymyalgia rheumatica (PMR), which causes limb girdle pain and stiffness as this patient describes. Progressive visual loss, due to the effect of the disease on the ophthalmic artery can befall up to 50%, in untreated patients.
Intracranial hemorrhage (choice A) is also very unlikely in this case. Longer-term headache can be seen with chronic subdural hematomas. However, this patient also has jaw claudication, symptoms of PMR, and an elevated ESR, which go along more with temporal arteritis.
Death from metastatic tumor (choice B) or herniation of the uncal region of the brain (choice C) would be of concern in the setting of a brain tumor. Although headache can be an initial symptom in patients with central nervous system malignancies, it is not a likely consideration in this case.
There is nothing to suggest from the case presentation that he is at high risk for an embolic stroke (choice E).
The correct answer is B. Coronary artery disease is the most prevalent disease in this age group. Cancer is also prevalent in this age group with lung, prostate, and colon cancer being the most common. Keep in mind the difference between prevalence and incidence when answering this sort of question. Prevalence is the percent of a given population effected at any given time. Incidence is the number of new cases arising for a period of time.
Accidental trauma (choice A) is the leading cause of death in the under 30 age group.
HIV (choice D) is prevalent in younger populations particularly in groups that have multiple sexual partners and use intravenous drugs.
Head-and-neck cancer (choice C) is one of the most common causes of cancer-related death, but would be less common than coronary artery disease in this age group.
Osteogenic sarcoma (choice E) occurs in the second to fifth decades of life in long tubular bones and would be relatively rare in this population.
Suicide (choice F) is second only to accidental trauma as the cause of death in the under 30 age group.
The correct answer is B. Infection is the most common cause of death in patients with chronic renal failure. This is followed closely by cardiovascular events. The etiology of increased risk of infection is multifactorial and involves a complex interplay of decreased immune response and complement activation by dialysis membranes all coupled with long-term indwelling components such as catheters. When a dialysis patient presents with infection, the first step in their management is to initiate broad antibiotic coverage based upon the likely causative organisms. This patient has an indwelling catheter and therefore has an increased risk of infection with both coagulase-positive and coagulase-negative Gram-positive cocci. Given the large percentage (25% at most centers) of methicillin resistant Staphylococcus aureus (MRSA), vancomycin is usually initiated until sensitivity data is available. An aminoglycoside is usually added to cover for very common Gram-negative infections.
Begin antibiotic therapy with gentamicin (choice A) is inadequate since the majority of infections in patients such as these will not be covered by an aminoglycoside alone.
Sending her urine for analysis and culture (choice C), although prudent, to perform this with a negative urine dipstick for WBCs, will not change your initial management and decision to cover the patient with broad spectrum antibiotics.
Performing a lumbar puncture and sending a CSF for analysis and culture (choice D) implies meningitis as a cause for the fevers. Meningitis is a rare cause of fevers generally. And although dialysis patients are at mildly increased risk of meningeal infections, in the absence of localized signs and symptoms, the likelihood of meningitis is very low and therefore the risk of an LP is not warranted.
Schedule emergent surgical removal of her Tesio catheter (choice E) is not an appropriate initial management step in a febrile patient. This may be indicated later in the course of care, but concern over removal before antibiotics have begun, is not appropriate.
"Growing pains", (choice A) are usually characterized by deep, severe, bilateral, diffuse pains that are worse at night. There is no associated limp.
Legg-Calve-Perthes disease (choice B), avascular necrosis of the femoral head, is characterized by hip and knee pain, a limp, and decreased range of motion. It usually affects boys between 4 to 8 years of age. Casting and surgery are treatment options.
Osteosarcoma (choice D), is the most common malignant bone tumor in kids. It occurs in the metaphyses of long bones, and presents with pain, swelling, and a palpable mass. X-rays show a lytic lesion with a "sunburst" pattern. Treatment is surgery.
Slipped Capital Femoral Epiphysis (choice E), is a disorder of overweight boys that is caused by a displacement of the femoral head from the femoral neck. There is knee or thigh pain, and a limp. Treatment is immediate surgical fixation
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The correct answer is D. The principle of individual autonomy is central to medicine. The only exceptions are if the patient has no clearly expressed wishes documented and is unable to make a decision or if the patient is deemed incompetent to make a decision. This patient is clearly competent to refuse treatment despite the wishes of his physician or neighbor. It is important to make the consequences of his decision clear to the patient before discharge and to tell him that he should return immediately should he change his mind.
Hospital care with or without intravenous antibiotics (choices A and B) is inappropriate as this patient is refusing hospital care.
This patient is clearly competent to refuse treatment, so he should not be admitted to the psychiatry ward (choice C) or given antidepressant therapy (choice F).
Consultation with an attorney (choice E) is not necessary as the patient is clearly competent to refuse medical care.
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A 39-year-old woman comes to the office for a periodic health maintenance examination. You have been treating her for anorexia nervosa for the past 15 years. She has required 4 hospitalizations during this time. She tells you that she is "doing as well as can be expected" now and that she has a new boyfriend who is very helpful. She is 157 cm (5 ft 2 in) tall and weighs 41 kg (90 lb). She admits that she still does not have a menstrual period. Her temperature is 36.7 C (98.0 F), blood pressure is 100/70 mm Hg, and her pulse is 55/min. Physical examination shows lanugo, dry, scaly skin, yellow discoloration of the palms, and pharyngeal abrasions. At this time the most correct statement is:
A. Electrocardiography will show shortened QT intervals
B. Fluoxetine is not effective in reducing binge eating and purging episodes
C. Her immune function is seriously affected and she is at risk for severe infections
D. Laboratory studies will show hyperkalemia
E. She is at an increased risk for developing osteoporosis
The correct answer is D. This patient is presenting with signs and symptoms of temporal arteritis, also known as giant cell arteritis. This disease is caused by inflammation of the large vessels off of the aortic arch, most commonly manifesting in the temporal artery. Biopsy will show mononuclear and giant multinucleated cells in the intima and media of the vessel. Classic symptoms are new onset temporal headaches in a patient over 60 years of age, jaw claudication as he describes, and an ESR that is markedly elevated. Patients often have pain to palpation over the temporal artery itself. There is also a high association with polymyalgia rheumatica (PMR), which causes limb girdle pain and stiffness as this patient describes. Progressive visual loss, due to the effect of the disease on the ophthalmic artery can befall up to 50%, in untreated patients.
Intracranial hemorrhage (choice A) is also very unlikely in this case. Longer-term headache can be seen with chronic subdural hematomas. However, this patient also has jaw claudication, symptoms of PMR, and an elevated ESR, which go along more with temporal arteritis.
Death from metastatic tumor (choice B) or herniation of the uncal region of the brain (choice C) would be of concern in the setting of a brain tumor. Although headache can be an initial symptom in patients with central nervous system malignancies, it is not a likely consideration in this case.
There is nothing to suggest from the case presentation that he is at high risk for an embolic stroke (choice E).
The correct answer is B. Coronary artery disease is the most prevalent disease in this age group. Cancer is also prevalent in this age group with lung, prostate, and colon cancer being the most common. Keep in mind the difference between prevalence and incidence when answering this sort of question. Prevalence is the percent of a given population effected at any given time. Incidence is the number of new cases arising for a period of time.
Accidental trauma (choice A) is the leading cause of death in the under 30 age group.
HIV (choice D) is prevalent in younger populations particularly in groups that have multiple sexual partners and use intravenous drugs.
Head-and-neck cancer (choice C) is one of the most common causes of cancer-related death, but would be less common than coronary artery disease in this age group.
Osteogenic sarcoma (choice E) occurs in the second to fifth decades of life in long tubular bones and would be relatively rare in this population.
Suicide (choice F) is second only to accidental trauma as the cause of death in the under 30 age group.
The correct answer is B. Infection is the most common cause of death in patients with chronic renal failure. This is followed closely by cardiovascular events. The etiology of increased risk of infection is multifactorial and involves a complex interplay of decreased immune response and complement activation by dialysis membranes all coupled with long-term indwelling components such as catheters. When a dialysis patient presents with infection, the first step in their management is to initiate broad antibiotic coverage based upon the likely causative organisms. This patient has an indwelling catheter and therefore has an increased risk of infection with both coagulase-positive and coagulase-negative Gram-positive cocci. Given the large percentage (25% at most centers) of methicillin resistant Staphylococcus aureus (MRSA), vancomycin is usually initiated until sensitivity data is available. An aminoglycoside is usually added to cover for very common Gram-negative infections.
Begin antibiotic therapy with gentamicin (choice A) is inadequate since the majority of infections in patients such as these will not be covered by an aminoglycoside alone.
Sending her urine for analysis and culture (choice C), although prudent, to perform this with a negative urine dipstick for WBCs, will not change your initial management and decision to cover the patient with broad spectrum antibiotics.
Performing a lumbar puncture and sending a CSF for analysis and culture (choice D) implies meningitis as a cause for the fevers. Meningitis is a rare cause of fevers generally. And although dialysis patients are at mildly increased risk of meningeal infections, in the absence of localized signs and symptoms, the likelihood of meningitis is very low and therefore the risk of an LP is not warranted.
Schedule emergent surgical removal of her Tesio catheter (choice E) is not an appropriate initial management step in a febrile patient. This may be indicated later in the course of care, but concern over removal before antibiotics have begun, is not appropriate.