02-13-2007, 03:01 PM
Record # 1
Question/Fact:
A 42-year-old man comes to your office complaining of feeling full after eating only salad at dinner for the past three months. He has felt fatigued recently while gardening and going to the shopping mall. Physical examination reveals a mild pallor, clear lungs, no murmurs, and no cervical or axillary adenopathy. There is massive splenomegaly, and the liver edge is felt one inch below the right costal margin. There are no ecchymoses or petechiae. Laboratory studies show: WBC 140,000/mm3, with 82% neutrophils, 10% basophils, and no blasts; hemoglobin 10 mg/dL, hematocrit 30%, platelets 320,000/mm3. The peripheral smear shows a left-shifted myeloid series and bands. What treatment would you recommend first?
(A) Leukapheresis
(B) Hydroxyurea
© Imitanib (Gleevec) STI 571
(D) Autologous bone-marrow transplant
(E) Interferon-alpha
Answer:
© Imitanib (Gleevec) STI 571
Explanation:
The best initial therapy for chronic myelogenous leukemia is the oral tyrosine kinase inhibitor, imitanib. Although this drug does not cure the disease, it offers an excellent hematologic response and often eliminates the Philadelphia chromosome. The only reliably curative treatment for CML is allogeneic bone-marrow transplantation, not an autologous transplantation. The crucial factor in the success of a transplant is the availability of HLA-matched siblings for donation. The cure rate is 70 to 80% if done within one year of diagnosis (if HLA-matched) but only 40 to 60% if an HLA match is found through a registry of nonfamilial donors.
The success of a drug used for CML is assessed by determining who becomes Philadelphia chromosome negative. If there is a complete cytogenetic response, survival rates are 90%. Hydroxyurea was formerly the treatment for CML patients awaiting transplantation. Hydroxyurea does not convert anyone to the Philadelphia chromosome-negative state and is only used to lower the cell count. Interferon-alpha was used to prolong the chronic phase of CML and after prolonged therapy could remove the Philadelphia chromosome in a minority of patients (<20-30%). Interferon has significant side effects, however, such as fatigue, myalgias, and anorexia, and it requires motivated patients. Imitanib or Gleevec (STI571) is a new oral drug that inhibits the tyrosine kinase activity of the bcr-abl gene and has shown excellent efficacy. There is a hematologic response in 80 to 90% of patients, and as many as three-quarters of these become Philadelphia chromosome negative. Although it is infinitely less dangerous than an allogeneic transplant, imitanib does not offer the same chance at a permanent cure.
Leukapheresis is performed if the patient shows signs of leukostasis or the sludging of the white cells in the vasculature, causing confusion, blurry vision, dyspnea, and stroke. This patient has a very high cell count but does not have any of these symptoms.
Record # 2
Question/Fact:
A 26-year-old athletic woman comes to the office for a routine visit. She jogs 2 to 5 miles per day and does not drink or smoke. Her only complaint is some occasional "bone pain" in her right lower leg when she runs. Her physical examination is unremarkable. Routine laboratory studies show: potassium 4.5 mEq/L; creatinine 0.8 mg/dL; and hematocrit 42%. Urinalysis shows a yellow color; pH 5.0; no white cells, red cells, or casts; and there is 1+ protein. Your initial management of this patient would be:
(A) Renal ultrasound
(B) 24-hour urine collection
© Split urine test
(D) Repeat urinalysis in 4 to 6 weeks
(E) Renal biopsy
Answer:
(D) Repeat urinalysis in 4 to 6 weeks
Explanation:
This patient has asymptomatic, non-nephrotic range proteinuria. There are four types of benign, isolated proteinuria:
1) Idiopathic transient proteinuria is usually observed in young adults and refers to a dipstick-positive proteinuria in an otherwise healthy individual that disappears spontaneously by the next clinic visit.
2) Functional proteinuria refers to a transient proteinuria during fever, exposure to cold, congestive heart failure, or obstructive sleep apnea. This phenomenon is presumed to be mediated through changes in the glomerular ultrafiltration pressure and/or membrane permeability.
3) Intermittent proteinuria patients have proteinuria in approximately half of their urine samples in the absence of other renal or systemic abnormalities.
4) Postural proteinuria is a proteinuria evident only in the upright position. This disorder affects 2 to 5 percent of adolescents and may be transient (80%) or fixed (20%). Fixed postural proteinuria resolves within 10 to 20 years in most cases.
All forms of benign, isolated proteinuria carry an excellent prognosis. Isolated proteinuria detected on multiple ambulatory visits (persistent isolated proteinuria) in both the recumbent and upright position usually signals a structural renal lesion. Virtually all glomerulopathies that induce nephrotic syndrome can cause isolated proteinuria. The most common lesion on renal biopsy is mild mesangial, proliferative glomerulonephritis with or without focal segmental glomerulosclerosis. Although this entity carries a worse prognosis than benign isolated proteinuria, the prognosis is relatively good, with only 20 to 40% of patients developing renal insufficiency after 20 years. Progression to renal failure is extremely rare.
Record # 3
Question/Fact:
A 37-year-old health care worker had a PPD skin test reactive at 17 mm ten years ago at the end of her internship. She never took the recommended isoniazid. What is appropriate for this patient?
(A) Do nothing
(B) Start isoniazid for the next nine months
© Perform a single PPD now
(D) Yearly chest x-rays
(E) Two-stage PPD testing
Answer:
(A) Do nothing
Explanation:
If the patient had not developed tuberculosis because of the previous exposure, she is not going to now. A positive skin test confers a 10% lifetime risk of developing tuberculosis. Almost all of this is within the first two years of developing a positive reaction. There is no point in giving a patient isoniazid now to prevent tuberculosis that would have happened years ago after the initial exposure. Once a tuberculosis skin test is positive, there is no point in ever repeating the test. It will always be positive. There is no benefit to yearly chest x-rays in anyone. Two-stage PPD testing is performed in those who have either never been tested before or who had negative skin tests in the past and it has been longer than a year since the last positive test. The two-stage test is to confirm that the first test is truly negative.
Record # 4
Question/Fact:
A 52-year-old Hispanic woman presents for an employment physical examination. The patient is a recent immigrant, and she hasn't seen a doctor for fifteen years. She denies chest pain or shortness of breath. She has good exercise tolerance and doesn't have a history of cardiac problems. The blood pressure is 165/70 mm Hg, and heart rate is 72/min. No jugulovenous distention is seen, and carotid bruits are absent. On heart examination, there is a normal S1, a physiologically split S2, a II/VI systolic ejection murmur at the base, and a III/VI diastolic decrescendo murmur at the left sternal border. This diastolic murmur is best heard when the patient holds her breath while sitting or leaning forward. Which of the following is most likely to benefit this patient?
(A) Digoxin
(B) Metoprolol
© Nifedipine
(D) Balloon manipulation
(E) Valve replacement
Answer:
© Nifedipine
Explanation:
This patient has aortic valve insufficiency (AI). She has a decrescendo diastolic murmur and a wide pulse pressure. The most likely cause of aortic insufficiency in this case is a congenital bicuspid aortic valve. The coexistence of aortic stenosis and AI is almost always from rheumatic fever or congenital disease. The first step is an echocardiogram to confirm the diagnosis, establish the cause of valve disease, and evaluate the ventricular size and systolic function. Some patients with chronic aortic regurgitation have irreversible left ventricular (LV) systolic dysfunction before the onset of symptoms.
If an echocardiogram reveals LV dilatation in patients with aortic valve insufficiency, afterload reduction therapy should be started with ACE inhibitors or nifedipine. Nifedipine can help delay the progression of the disease and delay the need for surgical valve replacement. Beta-blockers have not been found to be useful in AI. They may increase the severity of regurgitation by prolonging diastole. Valve replacement is not definitely necessary because she is not symptomatic. Valve replacement can be useful in asymptomatic patients if the patient has progressive LV dysfunction with an ejection fraction of <55%. Digoxin is of extremely limited value in aortic regurgitation.
Record # 5
Question/Fact:
A 60-year-old woman comes to your office with complaints of progressive fatigue. She is unable to make it through the day without tiring and hasn't been sleeping well due to waking up in the middle of the night short of breath. She is also concerned about a 10-pound weight gain over the past month. She has a past medical history of hypertension, hypercholesterolemia, and diabetes mellitus. Her medications include metformin, atenolol, hydrochlorothiazide, and atorvastatin. The doses haven't changed over the past two years. Vital signs are: blood pressure 167/96 mm Hg, heart rate 78/min, and respiratory rate 20/min. There is some mild jugular venous distension at 30 degrees, bibasilar rales, a holosystolic murmur at the apex radiating to the axilla, and a mild pitting edema of the ankles. Which of the following would be appropriate at this time?
(A) Echocardiogram to determine direction of action
(B) Digoxin
© Increase the dose of atenolol
(D) Start ACE inhibitors
(E) Stop the atenolol
Answer:
(A) Echocardiogram to determine direction of action
Explanation:
At this point, there is not enough information to determine if this is systolic or diastolic cardiac dysfunction. Longstanding hypertension can lead to either type of cardiomyopathy. If an S3 gallop was heard or an echocardiogram confirmed a low ejection fraction, then choice D, ACE inhibitors, would be correct. If an S4 was heard or an echocardiogram definitely showed diastolic dysfunction, then choice C, increasing the beta-blockers, would be the correct choice for treating diastolic dysfunction. Choice B, adding digoxin, would not be appropriate at this time. Digoxin is only helpful to decrease symptoms in systolic dysfunction. If the patient still has symptoms of dyspnea after starting an ACE inhibitor, then adding digoxin to relieve symptoms would be appropriate. Beta-blockers are appropriate for both systolic and diastolic dysfunction, so choice E, stopping the atenolol, is not appropriate. The best data for evidence for a decrease in mortality are for carvedilol and metoprolol, although it is probably an effect of the entire class of medications. Switching the diuretic to a loop diuretic, such as furosemide, and starting a salt-restricted diet are generally appropriate for all forms of congestive failure.
Record # 6
Question/Fact:
What is the appropriate mode of colorectal cancer screening for the following case?
A 41 year-old man with no family history of colon cancer and complains of 10 years of increasing constipation; his diet contains poor amounts of soluble fiber.
(A) Colonoscopy now and every 10 years
(B) Flexible sigmoidoscopy now and every 5 years
© Colonoscopy at age 50 and every 10 years
(D) Colonoscopy now and every 10 years
(E) Stool occult cards every year; colonoscopy if positive
(F) Colonoscopy at age 40 and every 5 years
(G) Colonoscopy in 3 years
(H) Colonoscopy in 1 year
(I) Colonoscopy every 1 to 2 years
Answer:
© Colonoscopy at age 50 and every 10 years
Explanation:
Colonoscopy is the preferred method of screening for colon cancer. Average-risk persons should undergo colonoscopy at age 50, and if normal, every 10 years. If a polyp is found, the colonoscopy should be repeated after 3 years. When there is a family history of colon cancer, screening should begin at age 40 or ten years prior to the age of the family member. The earlier date is respected. Follow-up examinations for persons with family histories of colon cancer should occur at 5-year intervals. When there are multiple family members, screening colonoscopy should be performed at age 25 and every 1 to 2 years (characteristic of persons with hereditary nonpolyposis colorectal cancer (Lynch syndrome). Colonoscopy is recommended 1 year after a hemicolectomy for colon cancer to verify the absence of recurrence and the presence of new lesions.
Record # 7
Question/Fact:
An elderly woman in a nursing home is being evaluated for her hypothyroidism. You find her thyroid-stimulating hormone (TSH) level to be elevated at 13 mU/L (normal 0.4-5 mU/L). She has been on the same dose of levothyroxine for six months since the time of diagnosis. Her past medical history is significant for anemia, peptic ulcer disease, and a stroke with right hemiparesis. She also has hypertension and chronic renal failure. The staff reports to you that she has had no change in her mental status, skin, or bowel movements. Since your last visit two months ago, an iron supplement was added to her regimen of amlodipine, famotidine, levothyroxine 75 μg, vitamin C, and aspirin. Her hematocrit is 40%, and rest of her physical examination is unremarkable. What is the next appropriate step in her management?
(A) Radioactive-iodine uptake level
(B) No change in management
© Titers against thyroperoxidase and thyroglobulin
(D) MRI of the brain
(E) Stop the iron and aspirin
(F) Stop the famotidine
Answer:
(E) Stop the iron and aspirin
Explanation:
This patient most likely has poor control of her hypothyroidism due to decreased absorption of her thyroid-hormone replacement because of an interaction with iron sulfate and vitamin C. Because her hematocrit is normal she doesn't need the iron anyway, and the vitamin C is most likely just being given to increase the absorption of the iron. Calcium supplementation and Carafate can also interfere with the absorption of thyroid hormone.
Record # 8
Question/Fact:
A 32-year-old woman with no significant past medical history comes to your office complaining of a severe headache. She describes a severe unilateral, nonpulsating, periorbital pain for about two hours. The patient has noticed that her right eye is red. She does not associate the headaches with any specific activity, food, or stressors. She denies fever or chills and has used ibuprofen and acetaminophen without relief. She is afebrile and has a blood pressure of 144/76 mm Hg. Physical examination reveals a morbidly obese female with a nontender face, temporal arteries, and sinuses. There is no neck stiffness. Her right eye is injected. The pupils are equal and round, but the right eye is nonreactive. The patient complains of blurred vision. Visual acuity testing shows 20/40 on the right and 20/20 on the left. Funduscopic and neurological examinations are normal. What would be the next step in the management of this patient?
(A) Oxygen inhalation therapy
(B) Acetazolamide
© Head CT scan
(D) Prednisone for 10 days, followed by rapid taper
(E) Pilocarpine
Answer:
(B) Acetazolamide
Explanation:
Because of this patient's history of headache, blurry vision, and a nonreactive pupil, this patient has acute-angle closure glaucoma. When the pupil becomes mid-dilated, the peripheral iris blocks aqueous outflow via the anterior chamber angle, and the intra-ocular pressure rises abruptly, producing pain, injection, corneal edema, and blurred vision. It is best treated acutely with acetazolamide to lower intraocular pressure. Topical beta-blockers can be used on a long-term basis to prevent an increase in intraocular pressure. Pilocarpine can be used to induce miosis and lower intraocular pressure as well, but it should be started after the acetazolamide. The symptoms of acute-angle closure glaucoma are similar to cluster headaches. These include a unilateral, nonthrobbing headache and the association with parasympathetic over activity, such as lacrimation, rhinorrhea, and injected conjunctiva. Cluster headaches last 30 minutes to two hours, are seen more often in men than woman, and often occur at the onset of sleep. Patients are usually hyperactive during the headache. Given the history of sudden headaches with no prior episodes and the nonreactive pupil, this patient is not likely to have cluster-type headaches. Oxygen inhalation and prednisone can be used to acutely treat cluster headaches.
Record # 9
Question/Fact:
A 60-year-old man presents with recurrent episodes of dyspnea on minimal exertion. He has a prior medical history significant for hypertrophic cardiomyopathy for 15 years, and for the past year his symptoms have become more severe and bothersome. He frequently complains of chest pain, orthopnea, nocturnal dyspnea, chronic nonproductive cough, weight gain, and peripheral edema. His medications include atenolol 50 mg BID, verapamil, disopyramide, and Lasix. Physical examination reveals an anxious tachypneic male who is afebrile with a blood pressure of 110/70 mm Hg without pulsus paradoxus. The respiratory rate is 30/min. Jugular veins are distended, and the heart sounds are distant. There are third and fourth heart sounds present, as well as bilateral rhonchi. The liver is enlarged, and pedal edema is present. The EKG shows nonspecific ST-T changes in the lateral leads. Chest x-ray reveals cardiomegaly with pulmonary congestion. The echocardiogram displays ventricular dilatation and mitral regurgitation with an ejection fraction of 35%. Three sets of cardiac enzymes are negative. What is the best medical management at this time?
(A) Add captopril to present regimen
(B) Increase the dose of Lasix and continue present regimen
© Stop the verapamil and disopyramide and start captopril
(D) Increase the dose of beta-blocker, verapamil, and Lasix; stop the disopyramide and start captopril
(E) Continue with present management
Answer:
© Stop the verapamil and disopyramide and start captopril
Explanation:
In 5% of patients, hypertrophic cardiomyopathy may "burn out" into a condition more typical of dilated cardiomyopathy. This is characterized by the development of thinner myocardial walls, diminishment of the outflow gradient, and the development of mitral regurgitation. These patients tend to have symptoms of congestive heart failure (CHF) at left ventricular ejection fractions that are not severely reduced, often in the range of 30 to 40%, as opposed to the usual case of dilated cardiomyopathy in which severe symptoms are rare above an ejection fraction of 25%. When this occurs, such patients should discontinue verapamil and disopyramide, which work to decrease inotropic state, and continue beta-blockers only at low doses and with caution. Patients should begin therapy with ACE inhibitors and diuretics as needed for fluid retention, as one would in any other patient with dilated cardiomyopathy.
Record # 10
Question/Fact:
A 28-year-old woman presents to her primary care clinic with complaints of fatigue and loss of appetite for the last three weeks. She has difficulty walking because of pain in her right knee and lower back. About two months ago, after coming back from a trip to Mexico, she was treated for diarrhea and symptoms of dysuria. Her past medical history is unremarkable. Her father has had severe chronic back pain since he was 30 years old. On physical examination, pertinent findings include moderate conjunctival hyperemia. Her range of motion is moderately decreased in the right knee joint and lumbar spine. There is some tenderness on palpation of the spine at the level of T12 to L5 bilaterally, as well as on palpation of the right knee. There is no visible joint swelling or deformity. During the examination, she mentions a somewhat increased vaginal discharge over the past two months. The discharge looks mucoid, but you don't see anything unusual on speculum examination. The smear from the cervix shows more than 10 neutrophils/hpf. While waiting for culture and other test results, what would be the most appropriate treatment for this patient?
(A) Indomethacin
(B) Methylprednisolone
© Sulfasalazine
(D) Physical therapy
(E) Doxycycline and ceftriaxone
Answer:
(E) Doxycycline and ceftriaxone
Explanation:
This patient presents with Reiter's syndrome as a manifestation of "reactive arthritis." Reactive arthritis is an acute, nonsuppurative, sterile inflammatory arthropathy, occurring after an infectious process but at a remote site. The microbial pathogens commonly associated with reactive arthritis are Shigella, Salmonella, Yersinia, Campylobacter, and Chlamydia. Reactive arthritis begins as an asymmetrical oligoarthritis, often preceded by an infectious event by 1 to 4 weeks. C. trachomatis is thought to be responsible for up to 10% of cases of early inflammatory arthritis. It develops in 1 to 3% of patients with chlamydial urethritis. The diagnosis is suggested by the detection of the involvement of at least one joint, symptoms of genitourinary infection, and the detection of Chlamydia on a genitourinary swabs or urine ligase chain reaction. Women may not have any urogenital manifestations at all. Only one third will have lower back pain, enthesitis, or radiographic sacroiliitis. In those with reactive arthritis secondary to chlamydia, the suggested treatment is a course of doxycycline.
NSAIDs, such as indomethacin or Naprosyn, are used in ankylosing spondylitis and Reiter's syndrome. NSAIDs alone can give some symptomatic improvement but won't treat the underlying cause. Systemic corticosteroids are reserved for severe disease flares. Slow-acting, antirheumatic drugs, such as sulfasalazine or methotrexate, should be considered when chronic peripheral arthritis, enthesitis, or spondylitis exists and is unresponsive to NSAIDs.
Record # 11
Question/Fact:
A 22-year-old man who is a recent immigrant from Pakistan comes to the emergency department because of a shock-like sensation in his left thigh on forward flexion. His left leg becomes fatigued easily. He has a fever and has been losing weight. He was treated for tuberculosis for a long time in his country but was noncompliant with the medications. Neurological examination demonstrates lower extremity paraparesis. An MRI of the spine reveals collapsed vertebrae at the level of T11 to L1. Which of the following is the most appropriate next step in his management?
(A) Start nafcillin
(B) Lumbar puncture
© Orthopedic consultation
(D) Bone scan
(E) Immediate radiotherapy
Answer:
© Orthopedic consultation
Explanation:
The clinical presentation and MRI findings are consistent with tuberculosis of the spine, or Pott's disease. The onset of symptoms is generally insidious and is often not even accompanied by fever. Tuberculosis usually involves the midthoracic spine. Anterior erosion of vertebral bodies causes collapse, resulting in kyphosis. Lumbar puncture is not needed, and in this case, it would be difficult due to distortion of the architecture of the vertebral body. Paraplegia is the most serious complication. In the presence of new paraparesis, immediate orthopedic consultation should be called for bone biopsy and possible fixation of the vertebrae. Bone scan will delay treatment, such as decompression of spinal cord, and adds little to the diagnosis because it will not substitute for a bone biopsy. Cultures of the bone can be done at the time of surgery. There is no evidence that this man has a malignant process, and immediate radiotherapy will not be appropriate at this time. The management of tuberculosis of the spine is with the same initial four-drug regimen used in pulmonary tuberculosis. The only major difference is that the duration of therapy should be extended to 12 months or longer.
Record # 12
Question/Fact:
A 65-year-old woman is admitted to the hospital on Friday night with an episode of squeezing, substernal chest pain that occurred while the patient was watching her favorite TV show. The pain lasted for twenty minutes and was not relieved by nitroglycerin. A dobutamine stress echocardiogram was done a month ago by her private physician, which showed posterior and lateral wall motion abnormalities. Her past medical history is significant for diabetes mellitus.
On arrival at the hospital, an EKG shows ST-segment depression in the lateral leads. She is started on aspirin, nitrates, beta-blockers, and intravenous unfractionated heparin. Three sets of cardiac enzymes are negative. A complete blood count shows a white cell count of 7,800/mm3, a hematocrit of 37%, and a platelet count of 180,000/mm3. The medications are continued, and she is transferred from the cardiac care unit on Sunday evening with plans for a coronary angiography the next day.
On Monday, the patient complains of pain in the right leg. The physical examination is unremarkable, except for moderate right-calf tenderness. The venous Duplex shows thrombosis of the right popliteal vein. Another complete blood count shows: WBC 9,900/mm3, hematocrit 38.8%; and platelets 45,000/mm3. The prothrombin time (PT) is 13.6 seconds, INR 1.0, and partial thromboplastin time (PTT) 68 seconds.
What is your next step in the management of this patient?
(A) Continue unfractionated heparin and start coumadin after the angiogram
(B) Switch unfractionated heparin to low-molecular-weight heparin
© Immediately stop heparin and remove heparin-coated catheters
(D) Corticosteroids
(E) Switch unfractionated heparin to lepirudin
Answer:
(E) Switch unfractionated heparin to lepirudin
Explanation:
This patient is suffering from heparin-induced thrombocytopenia (HIT) and also a deep venous thrombosis, which is most likely the result of this disorder. One to 3% of patients who receive unfractionated heparin will develop antibodies against platelets. All forms of heparin must be stopped when HIT occurs. You cannot just switch to low-molecular-weight heparin. Although low-molecular-weight heparin carries a much smaller risk of developing thrombocytopenia, 70% of the antibodies that develop will cross-react with low-molecular-weight heparin. Again, all heparins must be stopped because 30% of those with HIT will develop some form of thrombosis. Seventy-five percent of the time, the thrombi are venous, and only 25% are arterial. This patient has a thrombosis and therefore needs an alternate type of anticoagulation. Coumadin will not be effective rapidly enough, and the patient is also scheduled for angiography the following day.
Lepirudin is an analog of hirudin. These drugs are natural anticoagulants that inhibit thrombin and are derived from leeches. They do not cross-react with HIT-induced antibodies. Lepirudin can be monitored with the PTT. Danaparoid is a heparinoid that is no longer marketed in the United States.
Record # 13
Question/Fact:
A 35-year-old woman (gravida 1, para 0) presents to the emergency room at 32 weeks of pregnancy with complaints of progressive shortness of breath over the last week and paroxysmal nocturnal dyspnea for the last 3 weeks. The patient states that she recently started to use three pillows during sleep. The patient has a history of atrial fibrillation and uses digoxin for rate control. She got married two years ago and has been unable to conceive for more than one year. Her pulse is 120/min and irregular, and her blood pressure is 130/85 mm Hg. Physical examination reveals jugular venous distension, bibasilar lung crackles, a loud S1, an opening snap following S2, and a low-pitched diastolic murmur best heard in the left lateral decubitus position.
In the emergency department, the patient receives oxygen via nasal canula, furosemide 80 mg intravenously, and diltiazem 20 mg intravenously with no significant improvement in her symptoms. Echocardiography shows normal left ventricular systolic function with a mitral valve area of 0.9 cm2.
Which of the following is the most effective therapy in her management?
(A) Initiate therapy with lisinopril
(B) Start metoprolol
© Balloon valvuloplasty
(D) Cesarean section
(E) Increase the dose of digoxin
Answer:
© Balloon valvuloplasty
Explanation:
Almost all cases of mitral stenosis in adults are secondary to rheumatic heart disease. Most cases of mitral stenosis occur in women. Mitral valve stenosis impedes left ventricular filling, thereby increasing left atrial pressure as a pressure gradient develops across the mitral valve. Elevated left atrial pressure is referred to the lungs, where it produces pulmonary congestion. In mitral stenosis, the symptoms of left ventricular failure (dyspnea on exertion, orthopnea, and paroxysmal nocturnal dyspnea) are usually not due to left ventricular dysfunction, but rather to the mitral stenosis itself preventing the flow of blood out of the lungs.
The physiologic changes imposed by pregnancy can cause cardiac decompensation in any patient with a significant cardiac abnormality, especially in patients with mitral and aortic stenosis. This is because of the 50% rise in plasma volume routinely occurring during pregnancy. Symptoms of mitral stenosis become more severe during pregnancy because of the increase in diastolic flow and the rate-related shortening of the duration of diastole. Left atrial pressure rises, and dyspnea or pulmonary edema can occur in previously asymptomatic individuals. Atrial fibrillation also often leads to acute decompensation because of a shortened diastolic filling time as well.
Despite the appropriate use of diuretics to relieve pulmonary edema and the use of intravenous diltiazem to slow down the ventricular rate, in this case with atrial fibrillation, both the mother and the fetus are at high risk of injury because of pulmonary edema and hypoxemia. Balloon valvuloplasty is the most direct and effective form of therapy in this critical situation. Ending the pregnancy at 32 weeks' gestation is more hazardous to the fetus than the radiation exposure during the procedure. ACE inhibitors will not help, and besides that, they are contraindicated in pregnancy because of their teratogenic effects.
Record # 14
Question/Fact:
A 57-year-old man comes to the office with three days of cough and sputum production. Physical examination reveals rales at the left base. The chest x-ray shows a left lower lobe infiltrate. His respiratory rate is 22/min, and his oral temperature is 102 F. The pulse oximeter shows a 94% saturation on room air. How would you manage this patient?
(A) Wait for results of Gram stain and sputum culture
(B) Oral amoxicillin
© Oral gatifloxacin
(D) Intravenous cefuroxime
(E) Oral amoxicillin/clavulanic acid
Answer:
© Oral gatifloxacin
Explanation:
This patient can be safely treated as an outpatient. His respiratory rate, although raised at 22/min, is still <30/min. He is only mildly hypoxic. He is relatively young and has no other comorbid conditions, such as renal, liver, lung, or heart disease or cancer. Fever alone is not a reason to hospitalize someone. Sputum Gram stain and culture have a <50% sensitivity in the detection of a specific organism. Even if they were 100% sensitive, there would still be no reason to defer therapy until the results were obtained. Oral amoxicillin will not cover Legionella, Chlamydia, and Mycoplasma. It is also not as effective against pneumococcus as the newer fluoroquinolones, even when combined with clavulanic acid. Standard therapy for the outpatient management of community-acquired pneumonia is either with a macrolide or a new fluoroquinolone, such as levofloxacin, moxifloxacin, or gatifloxacin.
Record # 15
Question/Fact:
A 56-year-old man comes to the office for evaluation of his diabetes. He is well maintained on a sulfonylurea and metformin. He is a nonsmoker and has no history of hypertension or coronary disease. His father is the Jedi master Yoda who lived to be 900 years old without coronary disease. His glucose level today in the office is 135 mg/dL (normal 60-110 mg/dL), hemoglobin A1C 7.2% (normal 4-7%), and his LDL is 145 mg/dL. What is the most appropriate management of this patient?
(A) No further therapy indicated
(B) Step 2 diet, restricting lipid intake alone
© Niacin
(D) Statins
Answer:
(D) Statins
Explanation:
The presence of diabetes is considered the equivalent of coronary disease in the management of hyperlipidemia. Diabetes is such a strong risk for coronary disease and myocardial infarction that drug therapy should be started if the LDL is >130 mg/dL, with the goal of driving it under 100 mg/dL. It is optional even to start lipid-lowering drug therapy even with an LDL between 100-130 mg/dL. Niacin is not ideal in the management of those with diabetes because it impairs the ability to control glucose levels. Beside its effects on glucose levels, the best evidence for an improvement in mortality is with the use of the statins.
Record # 16
Question/Fact:
A 69-year-old man with a prolonged history of hypertension and diabetes mellitus is brought to the emergency department by his daughter with right lower extremity weakness and slurred speech. These symptoms developed suddenly over the last two hours. One month ago, he underwent laparoscopic cholecystectomy. He had a severe hematuria six weeks ago. Upon arrival, his blood pressure is 160/90 mm Hg, and his heart rate is 72/min. Neurological examination reveals right lower extremity weakness with 3/5 motor strength and decreased sensation in the same leg. Neck examination reveals a mild carotid bruit on the left. The EKG shows normal sinus rhythm. A CT scan of the head is normal. All laboratory tests are normal. Which of the following is most appropriate at this time?
(A) Aspirin 325 mg daily
(B) Aspirin 325 daily and dipyridamole 200 mg twice a day
© Coumadin
(D) tPA intravenously
(E) Heparin intravenously
Answer:
(D) tPA intravenously
Explanation:
This patient is evaluated within three hours after the onset of his neurological deficit, and he should receive tPA. It is the only approved medication for the treatment of acute ischemic stroke. It is effective in reducing neurological deficits in selected patients without CT-scan evidence of intracranial hemorrhage when administered within three hours of the onset of symptoms. Administration of tPA after three hours has not been proven to be effective or safe. A laparoscopic cholecystectomy a month ago and hematuria alone are not contraindications to the use of tPA. They are relatively minor risks for an increased risk of bleeding. Although the blood pressure is elevated in this case, it is still <185/110 mm Hg. Contraindications to the use of thrombolytics are a recent hemorrhage, an increased risk of hemorrhage, a recent myocardial infarction, an arterial puncture at a noncompressible site within the preceding seven days, major surgery within fourteen days, a systolic blood pressure above 185 mm Hg, or a diastolic pressure above 110 mm Hg. Gastrointestinal or severe urinary tract hemorrhage is also a contraindication to thrombolytic therapy. Heparin has no role in the management of patients with completed stroke, except when there is a cardiac source of embolization, such as a thrombus or atrial fibrillation. Treatment is then started with heparin and warfarin. There is an increased risk of early and serious intracranial and extracranial bleeding, and no long-term neurological benefit with heparin treatment for patients with acute ischemic stroke.
Record # 17
Question/Fact:
In determining fulminant hepatic failure, which of the following parameters should be closely monitored because it is best for predicting progression to failure?
(A) AST and ALT
(B) Alkaline phosphate
© Bilirubin
(D) Prothrombin time
(E) White blood cell count
Answer:
(D) Prothrombin time
Explanation:
In patients with severe hepatitis, the synthetic function of the liver most accurately predicts the mortality. The prothrombin time is based on the hepatic synthesis of factors 2, 5, 7, 9, 10, and fibrinogen. Thus, choice D is the correct answer.
Record # 18
Question/Fact:
A 35-year-old woman presents to your office complaining of a cough. She has a history of hyperthyroidism, which has been well controlled with propylthiouracil for the past 6 months. The cough has been getting progressively worse over the past week. She did not measure her temperature but does not complain of chills or night sweats. She has had no nausea, vomiting, or diarrhea. She is a nonsmoker. Her temperature is 101 F, with a blood pressure of 120/80 mm Hg, a heart rate of 88/min, and a respiratory rate of 22/min. Her oxygen saturation on room air is 92%. She has a slightly enlarged thyroid with no nodules or bruits. Her lung examination shows diffuse crackles bilaterally. The heart examination is normal, but a chest x-ray shows bilateral lobar consolidation. Which of the following would be the most appropriate for this patient?
(A) Thyroid-stimulating hormone (TSH)
(B) Chest CT scan
© CBC with manual differential, pan-cultures, and broad-spectrum antibiotics
(D) Bone marrow biopsy
(E) TSH-receptor antibody titers
Answer:
© CBC with manual differential, pan-cultures, and broad-spectrum antibiotics
Explanation:
This patient's hyperthyroidism is being treated with propylthiouracil (PTU); therefore, the patient is at risk for PTU-induced agranulocytosis. Any sign of illness in this patient must be quickly investigated for agranulocytosis. CBC would be the most appropriate initial test to see her neutrophil count. A patient with agranulocytosis may not show many systemic signs of infection. Similar to patients with neutropenia from cancer, a fever alone may be an indication to start immediate antibiotics. Due to a lack of neutrophils, the patient is at a high risk of bacterial and fungal infection. Although it is always appropriate to monitor the effect on the thyroid hormone levels, this is not as urgent as checking for the most life-threatening toxicity of PTU. A chest CT scan may be helpful later for evaluation of the abnormal lung examination and chest x-ray, but it would not be performed first. Bone marrow biopsy is never appropriate before checking the CBC.
Record # 19
Question/Fact:
A young man is found by the security guards outside the doors of the emergency room screaming and agitated. His blood pressure is 145/100 mm Hg, with a heart rate of 123/min, a temperature of 101.0 F, and a respiratory rate of 22/min. During the examination, the patient begins having a generalized seizure with urinary and fecal incontinence. The patient is intubated for airway protection, and the physical examination is continued. His pupils are dilated. His sodium is 143 mEq/L, with a creatinine of 0.9 mg/dL and a glucose of 126 mg/dL. Which of the following would be most useful for this patient?
(A) Propranolol
(B) Benzoylecgonine in the urine
© N-acetylcysteine
(D) Lumbar puncture and flumazenil
Answer:
(B) Benzoylecgonine in the urine
Explanation:
This patient's presentation is consistent with signs of cocaine intoxication. These patients can present with anxiety, tachycardia, hypertension, dilated pupils, agitation, muscular hyperactivity, and psychosis. The sustained hypertension may lead to intracranial hemorrhage, aortic dissection, or myocardial infarctions. The hypertension should not be treated with a pure beta-blocker alone because it may result in a paradoxical worsening of the hypertension due to an unopposed alpha-adrenergic effect. It should be treated with a vasodilatator such as nitroprusside or a combined alpha/beta agent, such as labetalol. N-acetylcysteine should be given for acetaminophen intoxication. Listeria infection is unlikely: This patient has no risk factors for it. Blood toxicology is not as specific as urine in most cases of qualitative drug screening, although it is better for qualitative tests. In cocaine intoxication, either cocaine or one of the metabolites, such as benzoylecgonine, are positive. This test is useful in this patient to establish a specific diagnosis. We have not yet truly proven why he is agitated.
Record # 20
Question/Fact:
A 45-year-old woman recently emigrated from Israel presents to the clinic with nasal discharge, weakness, nausea and vomiting, and decreased appetite for 3 weeks. She has had a low-grade temperature for a few days and has decided to come to the clinic today for antibiotics. On further questioning, she has had mild, diffuse, abdominal pain for the last month and has lost 5 lb as a result of having no appetite. She states that the abdominal pain is relieved by lying down and increases on exertion. She denies use of alcohol and smokes 1 pack of cigarettes per day but has had no desire for cigarettes over the past week. On physical examination, she is a healthy-appearing woman. Her temperature is 39.5 F, blood pressure is 135/75 mm Hg, heart rate is 78/min, and respirations are 18/min. She is anicteric and in no acute distress. There is some cervical lymphadenopathy, and the abdomen is mildly tender in the right upper quadrant.
Laboratory tests reveal the following: WBC 5,600/mm3, hemoglobin 10.8 mg/dL, hematocrit 38,8%, platelets 274,000/mm3, PT 28 seconds, INR 3.8, PTT 31 seconds, sodium 138 mEq/L, potassium 4.0 mEq/L, chloride 112 mEq/L, CO2 22 mEq/L, BUN 14 mg/dL, creatinine 0.8 mg/dL, and calcium 105 mg/dL. ALT is 382 U/L, AST is 327 U/L, and alkaline phosphatase is 121 U/L. Testing for hepatitis-C antibody is positive, hepatitis B e antigen (HbeAG) is negative, hepatis B e antibody (HbeAb) is negative, hepatitis B surface antigen (HbsAG) is negative, and hepatitis C virus (HCV) RNA is 580,000. What is the best treatment for this patient?
(A) Interferon-a-2b for six months
(B) Hepatitis B immunoglobulin (Ig) followed by hepatitis B virus (HBV) vaccine series
© Corticosteroids with morphine sulfate for pain relief
(D) Lamivudine
(E) Observation
Answer:
(A) Interferon-a-2b for six months
Explanation:
In patients with acute hepatitis C, early initiation of treatment with interferon will prevent the development of chronic hepatitis C in over 90% of persons. Lamivudine treats hepatitis e antigen-positive patients. Hepatitis B immunoglobulin (HBIG) is to prevent infection after an exposure to hepatitis-B surface-antigen-positive patients.
Record # 21
Question/Fact:
A 28-year-old female develops severe uterine bleeding with coagulation profile abnormalities eight hours after a successful delivery. She does not have any prior medical history, and the pregnancy was uncomplicated. She does not take any medications at home, except for multivitamins. The family history is unremarkable for any bleeding disorders. She has had tooth extractions in the past with no increase in bleeding.
On physical examination the patient presents as an anxious, nervous female, that looks her stated age. Her temperature is 97.8 F, blood pressure is 110/50 mm Hg, heart rate is 90/min, and the respiratory rate is 16/min. Her skin is pale. The uterus is enlarged, soft, and mildly painful on palpation. There are no external tears on vaginal exam. The amount of bleeding increases during palpation of the uterus.
Laboratory studies show the following results:
WBC 5,800/mm3; hemoglobin 9.8 g/dL; hematocrit 32.1 %, platelets 188,000/mm3; PT 12.4 seconds, INR 0.9, PTT 56 seconds. Bleeding time is normal. Fibrinogen 330 mg/mL; factor VIII: C level 22%.
The bleeding started three hours ago. During this time, the patient has received two units of packed red blood cells and six units of fresh frozen plasma (FFP), but the PTT remains elevated, and the bleeding still continues. Which test would be most useful in this situation?
(A) Von Willebrand's factor level
(B) Antiphospholipid antibody
© Russell viper venom (RVV) time
(D) PTT 1:1 mixing test
(E) Fibrin degradation products
Answer:
(D) PTT 1:1 mixing test
Explanation:
This patient developed factor VIII antibodies, which may happen postpartum or even sometimes without an obvious underlying cause. This can also occur in 15% of patients with factor VIII hemophilia, who have received infusions of fresh frozen plasma (FFP) or factor VIII replacement. In this disorder, the bleeding is usually severe, there is a decreased factor VIII level, and the PTT is prolonged. The fibrinogen level, PTT, and platelet count are not affected.
A plasma mixing test will show the presence of an inhibitor by the failure of normal plasma to correct the prolonged PTT. This test may require incubation for 2 to 4 hours. Factor VIII coagulant levels are low, which should not happen in von Willebrand's disease.
Hemophilia A is extremely unlikely in a woman because she would have to be homozygous recessive for the X-linked disorder. Factor VIII antibodies should be suspected in any patient with acquired severe bleeding and a prolonged PTT. The diagnosis is confirmed by mixing tests and by a failure of factor VIII concentrates to raise factor VIII:C levels.
Von Willebrand's disease is associated with mild mucosal bleeding. The measurement of von Willebrand's factor level will help you to distinguish between hemophilia A and von Willebrand's disease but won't explain why the coagulation profile was not corrected by transfusions of FFP.
Lupus anticoagulant is not associated with bleeding, unless a second disorder, such as thrombocytopenia or hypothrombinemia is present. Most commonly, it presents with thrombosis. Lupus anticoagulant also gives a prolonged PTT, and the mixing study will also fail to correct.
The Russell venom viper test is a more sensitive assay to demonstrate the presence of a lupus anticoagulant.
An antiphospholipid antibody is usually positive. Anticardiolipins are a related antiphospholipid antibody that can be detected by a separate assay.
Fibrin degradation products are elevated in DIC, which also presents with hypofibrinogenemia. D-dimer is the most sensitive of the fibrin-degradation products. The patient is usually seriously ill and has a low platelet count and elevation of the PT, as well as PTT. Bleeding may occur at any site, but spontaneous bleeding and oozing at venipuncture sites are important clues to the diagnosis.
Record # 22
Question/Fact:
A 35-year-old woman presents to the office with complaints of intermittent diarrhea over the past few weeks. She has lost 15 to 20 lb recently, despite a healthy appetite and normal food intake. She states that she frequently has loose, bulky, and foul-smelling stools. She denies any abdominal pain, the use of alcohol, and has no recent travel history. Past medical history is significant for insulin-dependent diabetes mellitus, diagnosed at age 14. At age 20, a perforated pyloric channel ulcer was treated surgically by a Roux en Y. Besides insulin, the patient takes no other medications.
On physical examination the vital signs are normal. She is a thin, pale-appearing woman. Her abdomen is soft and nontender with no hepatosplenomegaly. Her stool is negative for occult blood. She has diminished sensation over the bilateral lower extremities. Laboratory tests show: white blood cells: 7,500/mm3, hemoglobin 9.1 mg/dL, hematocrit 30%, platelets 450,000/mm3, mean corpuscular volume 105 μm3, vitamin B12 92 pg/mL (normal 330-1,025 pg/mL), and albumin 2.5 g/dL. The patient undergoes a 72-hour stool collection and excretes 21 grams of fat/24 hours (elevated). Stool culture is negative for parasites. What can the leading cause of malabsorption in this patient be attributed to?
(A) Pancreatic exocrine insufficiency
(B) Eosinophilic gastroenteritis
© Bacterial overgrowth secondary to Roux en Y surgery and diabetic enteropathy
(D) Pernicious anemia
(E) Crohn's disease
Answer:
© Bacterial overgrowth secondary to Roux en Y surgery and diabetic enteropathy
Explanation:
Bacterial overgrowth can cause diarrhea and malabsorption. Both a Roux en Y limb and diabetic enteropathy can result in bacterial overgrowth. The small intestine normally contains a small number of bacteria. Bacterial overgrowth results in malabsorption secondary to bacterial deconjugation of bile salts, leading to inadequate micelle formation. This will ultimately result in decreased fat absorption with steatorrhea. Microbes and bacteria uptake nutrients, thereby reducing absorption of vitamin B12 and carbohydrates. The proliferation of bacteria directly damages intestinal epithelial cells, as well as the brush border, impairing protein absorption. Passage of malabsorbed bile acids and carbohydrates into the colon leads to an osmotic and secretory diarrhea.
Record # 23
Question/Fact:
A 70-year-old woman has been brought to the emergency department for shortness of breath, cough, and lethargy for one day. The patient is confused. The daughter denies any problem of this type with the patient in the past, but she says cancerous polyps were found last year on colonoscopy. There has been progressive confusion and deterioration in her mental status over several years. On physical examination, the patient was found to be confused and has a temperature of 101 F, a blood pressure of 85/60 mm Hg, a pulse of 120/min, and a respiratory rate of 28/min. The chest examination shows decreased breath sounds with dullness to percussion on the right side at the base. The cardiac examination is normal. Laboratory studies reveal: white cell count 12,000/mm3, hematocrit 28%, platelets 400,000/mm3, sodium 135 mEq/L, bicarbonate 20 mEq/L, BUN 60 mg/dL, creatinine 3 mg/dL, and glucose 110 mg/dL. Urinalysis is positive for protein. Chest x-ray shows a right lower lobe infiltrate. Which of the following is correct about this patient?
(A) She has an approximately 30% chance to die with in 30 days
(B) Bronchoscopy is required
© The chance for Streptococcus pneumonia to be isolated is 80%
(D) Start ciprofloxacin
(E) Start vancomycin
Answer:
(A) She has an approximately 30% chance to die with in 30 days
Explanation:
The Pneumonia Outcome Research Team (PORT) scoring system is used to assess the risk of mortality on the basis of 19 clinical variables. The system stratifies patients into five mortality risk classes. This patient, with a score of >130, falls within the risk class V, which has a mortality risk between 27 and 31%. The following are the clinical variables for this patient and their scoring:
Age 70 (women: age - 10) = 60
Renal disease = 10
Hematocrit <30% = 10
Pleural effusion = 10
BUN >30 mg/dL = 20
Systolic pressure <90 mm Hg = 20
Neoplasm = 30
Total = 160
Patients with this class of mortality risk definitely need hospitalization. Streptococcus pneumoniae is the most common organism to be isolated in adults, but it is isolated in far less than 80% of cases. Prospective studies fail to identify a specific microbiologic cause of community-acquired pneumonia (CAP) in >50% of cases. Sputum Gram stain and culture should be done on all patients who are hospitalized. Bronchoscopy is not necessary unless the patient is severely ill, and sputum analysis fails to identify a specific causative organism. Ciprofloxacin is not an appropriate choice of medication for CAP; it has inadequate pneumococcal coverage. Vancomycin is used in pneumonia only if the causative organism has been definitely identified as penicillin-resistant pneumococcus. The other criteria for a serious pneumonia are: the presence of liver or heart disease, a pulse of >125/min, a sodium of <130 mEq/L, a glucose of >250 mEq/L, a pO2 of <60 mm Hg, a fever >40 C, and confusion.
Record # 24
Question/Fact:
A 28-year-old man with a history of renal insufficiency comes to your office with the gradual onset of mild lower back pain that has been radiating down to his thighs over the last two months. He also complains of bilateral shoulder and knee pain that improves with exercise. The patient states that his back is slightly stiff in the morning and that this stiffness is worsened by rest and relieved when he walks. He has never had any back pain before. On physical examination, he is afebrile. There is no local lower back tenderness, and he has a minimally decreased range of motion in the lumbar part of the spine. His rheumatoid factor is negative, and the ESR is 40 mm/h. Plain x-rays of the spine and pelvis are normal. Which of the following is the most appropriate management at this time?
(A) Hydroxychloroquine
(B) Prednisone
© Indomethacin
(D) Celecoxib
(E) Physical therapy
Answer:
(E) Physical therapy
Explanation:
This patient presents with what is most likely ankylosing spondylitis (AS). This is a chronic inflammatory disease of the joints of the axial skeleton, manifested by pain and progressive stiffness of the spine. He has had this pain for only two months, and the MRI will most likely not show any changes in the sacroiliac joints. He has very mild disease and no evidence as of yet of an anatomic abnormality. In fact, he is still missing many of the firm diagnostic criteria for AS, such as >3 months of symptoms, limited thoracic motion, iritis, and radiological evidence of sacroiliitis. Eventually, erosions and sclerosis of sacroiliac joints will become evident on radiographs. The term "bamboo spine" has been used to describe the late radiographic appearance of the spinal column. This patient has a history of renal insufficiency, and NSAIDs or COX-2 inhibitors may worsen his renal function and are thus contraindicated in this case. He now has only mild lower back pain with slight stiffness and will benefit from physical therapy, which might prevent axial skeleton deformity.
The onset of AS is usually gradual with intermittent bouts of back pain that may radiate down the thighs. The disease progresses in a cephalad direction, and back motion becomes progressively more limited. Transient acute arthritis of peripheral joints occurs in approximately 50% of cases, and permanent changes in the peripheral joints are seen in about 25%. This is most common of the hips, shoulders, and knees.
Record # 25
Question/Fact:
A 30-year-old woman in her thirtieth week of pregnancy comes in for her monthly evaluation by her obstetrician. As a part of her routine evaluation, she provides a urine specimen to the nurse. She has urinary frequency of 8 to 10 trips to the bathroom per day. She denies dysuria, hematuria, or fever. Her temperature is 99 F, with a pulse of 90/min and a blood pressure of 110/70 mm Hg. The examination reveals a gravid uterus compatible with 30 weeks of gestation. Her genital examination reveals no discharge or erythema. The urinalysis reveals 10 to 25 white cells/hpf with numerous bacteria but no red cells. What is your next step at this time?
(A) Do nothing
(B) Trimethoprim/sulfamethoxazole
© Ampicillin
(D) Gatifloxacin
(E) Renal ultrasound
(F) Ciprofloxacin
Answer:
© Ampicillin
Explanation:
This patient is presenting with a urinary tract infection (UTI) during pregnancy. Though minimally symptomatic at this time, it is important to treat all urinary infections during pregnancy. There is a 20 to 40% risk of developing pyelonephritis if untreated. A diagnostic study, such as a renal ultrasound, is not appropriate at this time. Of the antibiotics listed, only ampicillin is appropriate. Nitrofurantoin or cephalosporins, such as cephalexin, are safe to use in pregnancy but are not listed in the answer choices. Sulfa-based drugs can predispose to hyperbilirubinemia and kernicterus by interfering with bilirubin binding and should be avoided in the later trimesters. Fluoroquinolones, like gatifloxacin and ciprofloxacin, are potentially teratogenic upon the skeletal system and cartilage of the fetus.
Record # 26
Question/Fact:
A 78-year-old man with a history of coronary artery disease, congestive heart failure (CHF), and hyperlipidemia was admitted to CCU three days ago with a diagnosis of non-Q-wave myocardial infarction (MI). He was transferred to a regular floor yesterday after he was stabilized.
His current medications include aspirin, metoprolol 25 orally twice a day, nitroglycerin, furosemide 40 mg orally twice a day, and simvastatin. Physical examination shows a pulse of 82/min, a respiratory rate of 16/min, and a blood pressure of 112/62 mm Hg. There are minimal bibasilar crackles on lung examination, an S4 gallop on cardiac examination, and a trace edema in the extremities. Echocardiogram shows decreased left ventricular systolic function. You start him on captopril 6.25 mg every eight hours and double the dose with each additional dose until you reach the minimal effective dose of 50 mg three times a day. The following day, the nurse informs you that his blood pressure dropped to 95/49 mm Hg, with a pulse of 94/min, and she is hesitant to give any antihypertensive medications. What would be the most appropriate response?
(A) Discontinue metoprolol
(B) Discontinue captopril
© Reduce the dose of furosemide
(D) No intervention because his blood pressure drop is transient
(E) Hold all medications
Answer:
© Reduce the dose of furosemide
Explanation:
ACE inhibitors such as captopril have become standard therapy for CHF because they have been shown to decrease mortality. They should be started with small doses and titrated up as tolerated because of a possible hypotensive effect. The final dosage should be 50 mg orally every 8 hours. This is the minimum needed to achieve the needed effect on relieving afterload. Remember, however, that there is virtually no reason to use a cumbersome three-times-a-day medication such as captopril for an outpatient when drugs such as ramipril, quinapril, lisinopril, and fosinopril can be used once a day and with far greater adherence.
This patient developed his hypotensive episode a full day after being on a higher dose of the ACE inhibitor. The hypotensive episode may therefore not be directly related to just the use of the ACE inhibitor. The diuretic dose may need downward adjustment or be withheld for 24 hours. Besides having only minimal signs of fluid overload, the question is making sure you know that it is more important to first remove drugs that don't have a definite effect on lowering mortality. In addition, reducing the dose of Lasix to 20 or 40 mg once a day will not result in any harm to the patient.
Record # 27
Question/Fact:
A 45-year-old man has had dysphagia of increasing severity over the past year. He has recently lost 5 lb. The upper endoscopy shows distal erythema of the esophageal mucosa and resistance to the passage of the endoscope at the esophagogastric junction. No anatomical lesion is seen. Esophageal motility shows lack of peristalsis in the body of the esophagus and a high-pressure lower esophageal sphincter with incomplete relaxation with swallowing. Which of the following treatments would NOT be appropriate for this patient?
(A) Pneumatic dilatation
(B) Botulinum toxin injection
© Surgical myotomy
(D) Anticholinergic agents
(E) Calcium-channel blockers
Answer:
(D) Anticholinergic agents
Explanation:
Achalasia is an idiopathic disorder characterized by disturbed esophageal motility and high pressure of the lower esophageal sphincter, with incomplete relaxation during normal swallowing. Most patients with achalasia are treated with pneumatic dilatation. Botulinum toxin and calcium-channel blockers can be attempted with some success. The surgical Heller myotomy is the most effective surgical technique. Anticholinergic agents only exacerbate the disease.
Record # 28
Question/Fact:
A 72-year-old man is admitted to the hospital from a nursing home for a pressure ulcer of his ankle. The x-ray of the foot shows bone destruction consistent with osteomyelitis. A biopsy of the bone reveals Escherichia coli that is sensitive to every antibiotic tested. What is the most appropriate therapy?
(A) Intravenous piperacillin-tazobactam for six weeks
(B) Intravenous ampicillin-sulbactam for six weeks
© Oral amoxicillin-clavulanic acid for six weeks
(D) Oral ciprofloxacin for six weeks
(E) Intravenous ceftazidime for six weeks
Answer:
(D) Oral ciprofloxacin for six weeks
Explanation:
Although all of the medications listed will be effective for a sensitive E. coli, the most convenient therapy is oral ciprofloxacin. Oral quinolones, specifically ciprofloxacin, are equal in efficacy to intravenous therapy.
Record # 29
Question/Fact:
A 50-year-old man is brought in by an ambulance to the emergency department because of increased shortness of breath for the past two weeks. He feels short of breath on exertion for the last two years, uses at least two pillows at night, and denies chest pain or palpitations. He has no history of ischemic heart disease. He is not compliant with his medications and forgets to take his "water pills." He has five vodka martinis every night. The patient has been smoking one pack of cigarettes a day for the past 30 years. Last month he was treated in another hospital for alcohol withdrawal symptoms.
On physical examination, the patient is lying in bed and is slightly short of breath. His temperature is 97.0 F, heart rate is 78/min, respiratory rate is 22/min, and blood pressure is 150/80 mm Hg. The neck veins are distended. There is cardiomegaly and an S3 gallop. On lung auscultation, there are crackles at both bases. The liver edge is palpated 2 cm below the right costal margin. There is 1+ bilateral leg edema.
EKG shows low QRS voltage, nonspecific ST-segment and T changes. The chest x-ray shows cardiomegaly and mild pulmonary congestion. Left ventricular dilation is found by echocardiogram.
What is your choice of therapy at this time?
(A) Captopril, furosemide, beta-blockers
(B) Losartan, furosemide, coumadin
© Captopril, spironolactone, digoxin
(D) Captopril, furosemide, digoxin, coumadin
Answer:
(A) Captopril, furosemide, beta-blockers
Explanation:
This patient presents with dilated cardiomyopathy and displays signs of biventricular heart failure. Chronic alcohol abuse is one of the most frequent causes of dilated cardiomyopathy. The management is similar to that of congestive heart failure related to ischemia. The offending agent should be discontinued. Initial treatment usually consists of diuretics, ACE inhibitors, and beta-blockers. The addition of digoxin depends of presence of decreased left ventricular function and the persistence of symptoms despite the use of ACE inhibitors, diuretics, and beta-blockers. Chronic anticoagulation must be considered but should only be used if there were evidence of thrombosis. In addition, coumadin should be used with extreme caution in an alcoholic. Angiotensin-receptor blockers are indicated when patients cannot tolerate ACE inhibitors because of adverse effects, such as a cough.
Record # 30
Question/Fact:
A 68-year-old man with a history of hypertension is brought to your office with complaints of progressive memory loss and poor concentration over the last four months. According to the patient's wife, he has become forgetful, irritable, and emotionally labile. He is apathetic and has little spontaneous speech. Recently, the patient developed urinary incontinence and gait impairment. He has to take very short steps to walk; however, there is no shuffling gait. His funduscopic examination is normal. There is mild bradykinesia but no tremor or rigidity of the extremities. Lumbar puncture is performed in the office and led to an improved gait. Which of the following is the most appropriate management for this patient?
(A) Ventriculoperitoneal shunting
(B) Bromocriptine
© Aspirin
(D) Donepezil
(E) Penicillin
Answer:
(A) Ventriculoperitoneal shunting
Explanation:
This patient presents with normal-pressure hydrocephalus (NPH). NPH should be considered in mildly demented patients with gait disturbances and urinary incontinence. Mild, generalized slowness of movement and thought are frequently present in NPH and may be due to excessive cerebrospinal-fluid production or insufficient absorption. Large-volume lumbar puncture can lead to an improvement in the gait. Patients with NPH are more likely to benefit from ventriculoperitoneal shunting if there has been a demonstrated improvement in symptoms after a lumbar puncture. The lumbar puncture is not absolutely essential. If a patient has all the classic symptoms of NPH, you can go straight to ventriculoperitoneal shunting.
The essent
Question/Fact:
A 42-year-old man comes to your office complaining of feeling full after eating only salad at dinner for the past three months. He has felt fatigued recently while gardening and going to the shopping mall. Physical examination reveals a mild pallor, clear lungs, no murmurs, and no cervical or axillary adenopathy. There is massive splenomegaly, and the liver edge is felt one inch below the right costal margin. There are no ecchymoses or petechiae. Laboratory studies show: WBC 140,000/mm3, with 82% neutrophils, 10% basophils, and no blasts; hemoglobin 10 mg/dL, hematocrit 30%, platelets 320,000/mm3. The peripheral smear shows a left-shifted myeloid series and bands. What treatment would you recommend first?
(A) Leukapheresis
(B) Hydroxyurea
© Imitanib (Gleevec) STI 571
(D) Autologous bone-marrow transplant
(E) Interferon-alpha
Answer:
© Imitanib (Gleevec) STI 571
Explanation:
The best initial therapy for chronic myelogenous leukemia is the oral tyrosine kinase inhibitor, imitanib. Although this drug does not cure the disease, it offers an excellent hematologic response and often eliminates the Philadelphia chromosome. The only reliably curative treatment for CML is allogeneic bone-marrow transplantation, not an autologous transplantation. The crucial factor in the success of a transplant is the availability of HLA-matched siblings for donation. The cure rate is 70 to 80% if done within one year of diagnosis (if HLA-matched) but only 40 to 60% if an HLA match is found through a registry of nonfamilial donors.
The success of a drug used for CML is assessed by determining who becomes Philadelphia chromosome negative. If there is a complete cytogenetic response, survival rates are 90%. Hydroxyurea was formerly the treatment for CML patients awaiting transplantation. Hydroxyurea does not convert anyone to the Philadelphia chromosome-negative state and is only used to lower the cell count. Interferon-alpha was used to prolong the chronic phase of CML and after prolonged therapy could remove the Philadelphia chromosome in a minority of patients (<20-30%). Interferon has significant side effects, however, such as fatigue, myalgias, and anorexia, and it requires motivated patients. Imitanib or Gleevec (STI571) is a new oral drug that inhibits the tyrosine kinase activity of the bcr-abl gene and has shown excellent efficacy. There is a hematologic response in 80 to 90% of patients, and as many as three-quarters of these become Philadelphia chromosome negative. Although it is infinitely less dangerous than an allogeneic transplant, imitanib does not offer the same chance at a permanent cure.
Leukapheresis is performed if the patient shows signs of leukostasis or the sludging of the white cells in the vasculature, causing confusion, blurry vision, dyspnea, and stroke. This patient has a very high cell count but does not have any of these symptoms.
Record # 2
Question/Fact:
A 26-year-old athletic woman comes to the office for a routine visit. She jogs 2 to 5 miles per day and does not drink or smoke. Her only complaint is some occasional "bone pain" in her right lower leg when she runs. Her physical examination is unremarkable. Routine laboratory studies show: potassium 4.5 mEq/L; creatinine 0.8 mg/dL; and hematocrit 42%. Urinalysis shows a yellow color; pH 5.0; no white cells, red cells, or casts; and there is 1+ protein. Your initial management of this patient would be:
(A) Renal ultrasound
(B) 24-hour urine collection
© Split urine test
(D) Repeat urinalysis in 4 to 6 weeks
(E) Renal biopsy
Answer:
(D) Repeat urinalysis in 4 to 6 weeks
Explanation:
This patient has asymptomatic, non-nephrotic range proteinuria. There are four types of benign, isolated proteinuria:
1) Idiopathic transient proteinuria is usually observed in young adults and refers to a dipstick-positive proteinuria in an otherwise healthy individual that disappears spontaneously by the next clinic visit.
2) Functional proteinuria refers to a transient proteinuria during fever, exposure to cold, congestive heart failure, or obstructive sleep apnea. This phenomenon is presumed to be mediated through changes in the glomerular ultrafiltration pressure and/or membrane permeability.
3) Intermittent proteinuria patients have proteinuria in approximately half of their urine samples in the absence of other renal or systemic abnormalities.
4) Postural proteinuria is a proteinuria evident only in the upright position. This disorder affects 2 to 5 percent of adolescents and may be transient (80%) or fixed (20%). Fixed postural proteinuria resolves within 10 to 20 years in most cases.
All forms of benign, isolated proteinuria carry an excellent prognosis. Isolated proteinuria detected on multiple ambulatory visits (persistent isolated proteinuria) in both the recumbent and upright position usually signals a structural renal lesion. Virtually all glomerulopathies that induce nephrotic syndrome can cause isolated proteinuria. The most common lesion on renal biopsy is mild mesangial, proliferative glomerulonephritis with or without focal segmental glomerulosclerosis. Although this entity carries a worse prognosis than benign isolated proteinuria, the prognosis is relatively good, with only 20 to 40% of patients developing renal insufficiency after 20 years. Progression to renal failure is extremely rare.
Record # 3
Question/Fact:
A 37-year-old health care worker had a PPD skin test reactive at 17 mm ten years ago at the end of her internship. She never took the recommended isoniazid. What is appropriate for this patient?
(A) Do nothing
(B) Start isoniazid for the next nine months
© Perform a single PPD now
(D) Yearly chest x-rays
(E) Two-stage PPD testing
Answer:
(A) Do nothing
Explanation:
If the patient had not developed tuberculosis because of the previous exposure, she is not going to now. A positive skin test confers a 10% lifetime risk of developing tuberculosis. Almost all of this is within the first two years of developing a positive reaction. There is no point in giving a patient isoniazid now to prevent tuberculosis that would have happened years ago after the initial exposure. Once a tuberculosis skin test is positive, there is no point in ever repeating the test. It will always be positive. There is no benefit to yearly chest x-rays in anyone. Two-stage PPD testing is performed in those who have either never been tested before or who had negative skin tests in the past and it has been longer than a year since the last positive test. The two-stage test is to confirm that the first test is truly negative.
Record # 4
Question/Fact:
A 52-year-old Hispanic woman presents for an employment physical examination. The patient is a recent immigrant, and she hasn't seen a doctor for fifteen years. She denies chest pain or shortness of breath. She has good exercise tolerance and doesn't have a history of cardiac problems. The blood pressure is 165/70 mm Hg, and heart rate is 72/min. No jugulovenous distention is seen, and carotid bruits are absent. On heart examination, there is a normal S1, a physiologically split S2, a II/VI systolic ejection murmur at the base, and a III/VI diastolic decrescendo murmur at the left sternal border. This diastolic murmur is best heard when the patient holds her breath while sitting or leaning forward. Which of the following is most likely to benefit this patient?
(A) Digoxin
(B) Metoprolol
© Nifedipine
(D) Balloon manipulation
(E) Valve replacement
Answer:
© Nifedipine
Explanation:
This patient has aortic valve insufficiency (AI). She has a decrescendo diastolic murmur and a wide pulse pressure. The most likely cause of aortic insufficiency in this case is a congenital bicuspid aortic valve. The coexistence of aortic stenosis and AI is almost always from rheumatic fever or congenital disease. The first step is an echocardiogram to confirm the diagnosis, establish the cause of valve disease, and evaluate the ventricular size and systolic function. Some patients with chronic aortic regurgitation have irreversible left ventricular (LV) systolic dysfunction before the onset of symptoms.
If an echocardiogram reveals LV dilatation in patients with aortic valve insufficiency, afterload reduction therapy should be started with ACE inhibitors or nifedipine. Nifedipine can help delay the progression of the disease and delay the need for surgical valve replacement. Beta-blockers have not been found to be useful in AI. They may increase the severity of regurgitation by prolonging diastole. Valve replacement is not definitely necessary because she is not symptomatic. Valve replacement can be useful in asymptomatic patients if the patient has progressive LV dysfunction with an ejection fraction of <55%. Digoxin is of extremely limited value in aortic regurgitation.
Record # 5
Question/Fact:
A 60-year-old woman comes to your office with complaints of progressive fatigue. She is unable to make it through the day without tiring and hasn't been sleeping well due to waking up in the middle of the night short of breath. She is also concerned about a 10-pound weight gain over the past month. She has a past medical history of hypertension, hypercholesterolemia, and diabetes mellitus. Her medications include metformin, atenolol, hydrochlorothiazide, and atorvastatin. The doses haven't changed over the past two years. Vital signs are: blood pressure 167/96 mm Hg, heart rate 78/min, and respiratory rate 20/min. There is some mild jugular venous distension at 30 degrees, bibasilar rales, a holosystolic murmur at the apex radiating to the axilla, and a mild pitting edema of the ankles. Which of the following would be appropriate at this time?
(A) Echocardiogram to determine direction of action
(B) Digoxin
© Increase the dose of atenolol
(D) Start ACE inhibitors
(E) Stop the atenolol
Answer:
(A) Echocardiogram to determine direction of action
Explanation:
At this point, there is not enough information to determine if this is systolic or diastolic cardiac dysfunction. Longstanding hypertension can lead to either type of cardiomyopathy. If an S3 gallop was heard or an echocardiogram confirmed a low ejection fraction, then choice D, ACE inhibitors, would be correct. If an S4 was heard or an echocardiogram definitely showed diastolic dysfunction, then choice C, increasing the beta-blockers, would be the correct choice for treating diastolic dysfunction. Choice B, adding digoxin, would not be appropriate at this time. Digoxin is only helpful to decrease symptoms in systolic dysfunction. If the patient still has symptoms of dyspnea after starting an ACE inhibitor, then adding digoxin to relieve symptoms would be appropriate. Beta-blockers are appropriate for both systolic and diastolic dysfunction, so choice E, stopping the atenolol, is not appropriate. The best data for evidence for a decrease in mortality are for carvedilol and metoprolol, although it is probably an effect of the entire class of medications. Switching the diuretic to a loop diuretic, such as furosemide, and starting a salt-restricted diet are generally appropriate for all forms of congestive failure.
Record # 6
Question/Fact:
What is the appropriate mode of colorectal cancer screening for the following case?
A 41 year-old man with no family history of colon cancer and complains of 10 years of increasing constipation; his diet contains poor amounts of soluble fiber.
(A) Colonoscopy now and every 10 years
(B) Flexible sigmoidoscopy now and every 5 years
© Colonoscopy at age 50 and every 10 years
(D) Colonoscopy now and every 10 years
(E) Stool occult cards every year; colonoscopy if positive
(F) Colonoscopy at age 40 and every 5 years
(G) Colonoscopy in 3 years
(H) Colonoscopy in 1 year
(I) Colonoscopy every 1 to 2 years
Answer:
© Colonoscopy at age 50 and every 10 years
Explanation:
Colonoscopy is the preferred method of screening for colon cancer. Average-risk persons should undergo colonoscopy at age 50, and if normal, every 10 years. If a polyp is found, the colonoscopy should be repeated after 3 years. When there is a family history of colon cancer, screening should begin at age 40 or ten years prior to the age of the family member. The earlier date is respected. Follow-up examinations for persons with family histories of colon cancer should occur at 5-year intervals. When there are multiple family members, screening colonoscopy should be performed at age 25 and every 1 to 2 years (characteristic of persons with hereditary nonpolyposis colorectal cancer (Lynch syndrome). Colonoscopy is recommended 1 year after a hemicolectomy for colon cancer to verify the absence of recurrence and the presence of new lesions.
Record # 7
Question/Fact:
An elderly woman in a nursing home is being evaluated for her hypothyroidism. You find her thyroid-stimulating hormone (TSH) level to be elevated at 13 mU/L (normal 0.4-5 mU/L). She has been on the same dose of levothyroxine for six months since the time of diagnosis. Her past medical history is significant for anemia, peptic ulcer disease, and a stroke with right hemiparesis. She also has hypertension and chronic renal failure. The staff reports to you that she has had no change in her mental status, skin, or bowel movements. Since your last visit two months ago, an iron supplement was added to her regimen of amlodipine, famotidine, levothyroxine 75 μg, vitamin C, and aspirin. Her hematocrit is 40%, and rest of her physical examination is unremarkable. What is the next appropriate step in her management?
(A) Radioactive-iodine uptake level
(B) No change in management
© Titers against thyroperoxidase and thyroglobulin
(D) MRI of the brain
(E) Stop the iron and aspirin
(F) Stop the famotidine
Answer:
(E) Stop the iron and aspirin
Explanation:
This patient most likely has poor control of her hypothyroidism due to decreased absorption of her thyroid-hormone replacement because of an interaction with iron sulfate and vitamin C. Because her hematocrit is normal she doesn't need the iron anyway, and the vitamin C is most likely just being given to increase the absorption of the iron. Calcium supplementation and Carafate can also interfere with the absorption of thyroid hormone.
Record # 8
Question/Fact:
A 32-year-old woman with no significant past medical history comes to your office complaining of a severe headache. She describes a severe unilateral, nonpulsating, periorbital pain for about two hours. The patient has noticed that her right eye is red. She does not associate the headaches with any specific activity, food, or stressors. She denies fever or chills and has used ibuprofen and acetaminophen without relief. She is afebrile and has a blood pressure of 144/76 mm Hg. Physical examination reveals a morbidly obese female with a nontender face, temporal arteries, and sinuses. There is no neck stiffness. Her right eye is injected. The pupils are equal and round, but the right eye is nonreactive. The patient complains of blurred vision. Visual acuity testing shows 20/40 on the right and 20/20 on the left. Funduscopic and neurological examinations are normal. What would be the next step in the management of this patient?
(A) Oxygen inhalation therapy
(B) Acetazolamide
© Head CT scan
(D) Prednisone for 10 days, followed by rapid taper
(E) Pilocarpine
Answer:
(B) Acetazolamide
Explanation:
Because of this patient's history of headache, blurry vision, and a nonreactive pupil, this patient has acute-angle closure glaucoma. When the pupil becomes mid-dilated, the peripheral iris blocks aqueous outflow via the anterior chamber angle, and the intra-ocular pressure rises abruptly, producing pain, injection, corneal edema, and blurred vision. It is best treated acutely with acetazolamide to lower intraocular pressure. Topical beta-blockers can be used on a long-term basis to prevent an increase in intraocular pressure. Pilocarpine can be used to induce miosis and lower intraocular pressure as well, but it should be started after the acetazolamide. The symptoms of acute-angle closure glaucoma are similar to cluster headaches. These include a unilateral, nonthrobbing headache and the association with parasympathetic over activity, such as lacrimation, rhinorrhea, and injected conjunctiva. Cluster headaches last 30 minutes to two hours, are seen more often in men than woman, and often occur at the onset of sleep. Patients are usually hyperactive during the headache. Given the history of sudden headaches with no prior episodes and the nonreactive pupil, this patient is not likely to have cluster-type headaches. Oxygen inhalation and prednisone can be used to acutely treat cluster headaches.
Record # 9
Question/Fact:
A 60-year-old man presents with recurrent episodes of dyspnea on minimal exertion. He has a prior medical history significant for hypertrophic cardiomyopathy for 15 years, and for the past year his symptoms have become more severe and bothersome. He frequently complains of chest pain, orthopnea, nocturnal dyspnea, chronic nonproductive cough, weight gain, and peripheral edema. His medications include atenolol 50 mg BID, verapamil, disopyramide, and Lasix. Physical examination reveals an anxious tachypneic male who is afebrile with a blood pressure of 110/70 mm Hg without pulsus paradoxus. The respiratory rate is 30/min. Jugular veins are distended, and the heart sounds are distant. There are third and fourth heart sounds present, as well as bilateral rhonchi. The liver is enlarged, and pedal edema is present. The EKG shows nonspecific ST-T changes in the lateral leads. Chest x-ray reveals cardiomegaly with pulmonary congestion. The echocardiogram displays ventricular dilatation and mitral regurgitation with an ejection fraction of 35%. Three sets of cardiac enzymes are negative. What is the best medical management at this time?
(A) Add captopril to present regimen
(B) Increase the dose of Lasix and continue present regimen
© Stop the verapamil and disopyramide and start captopril
(D) Increase the dose of beta-blocker, verapamil, and Lasix; stop the disopyramide and start captopril
(E) Continue with present management
Answer:
© Stop the verapamil and disopyramide and start captopril
Explanation:
In 5% of patients, hypertrophic cardiomyopathy may "burn out" into a condition more typical of dilated cardiomyopathy. This is characterized by the development of thinner myocardial walls, diminishment of the outflow gradient, and the development of mitral regurgitation. These patients tend to have symptoms of congestive heart failure (CHF) at left ventricular ejection fractions that are not severely reduced, often in the range of 30 to 40%, as opposed to the usual case of dilated cardiomyopathy in which severe symptoms are rare above an ejection fraction of 25%. When this occurs, such patients should discontinue verapamil and disopyramide, which work to decrease inotropic state, and continue beta-blockers only at low doses and with caution. Patients should begin therapy with ACE inhibitors and diuretics as needed for fluid retention, as one would in any other patient with dilated cardiomyopathy.
Record # 10
Question/Fact:
A 28-year-old woman presents to her primary care clinic with complaints of fatigue and loss of appetite for the last three weeks. She has difficulty walking because of pain in her right knee and lower back. About two months ago, after coming back from a trip to Mexico, she was treated for diarrhea and symptoms of dysuria. Her past medical history is unremarkable. Her father has had severe chronic back pain since he was 30 years old. On physical examination, pertinent findings include moderate conjunctival hyperemia. Her range of motion is moderately decreased in the right knee joint and lumbar spine. There is some tenderness on palpation of the spine at the level of T12 to L5 bilaterally, as well as on palpation of the right knee. There is no visible joint swelling or deformity. During the examination, she mentions a somewhat increased vaginal discharge over the past two months. The discharge looks mucoid, but you don't see anything unusual on speculum examination. The smear from the cervix shows more than 10 neutrophils/hpf. While waiting for culture and other test results, what would be the most appropriate treatment for this patient?
(A) Indomethacin
(B) Methylprednisolone
© Sulfasalazine
(D) Physical therapy
(E) Doxycycline and ceftriaxone
Answer:
(E) Doxycycline and ceftriaxone
Explanation:
This patient presents with Reiter's syndrome as a manifestation of "reactive arthritis." Reactive arthritis is an acute, nonsuppurative, sterile inflammatory arthropathy, occurring after an infectious process but at a remote site. The microbial pathogens commonly associated with reactive arthritis are Shigella, Salmonella, Yersinia, Campylobacter, and Chlamydia. Reactive arthritis begins as an asymmetrical oligoarthritis, often preceded by an infectious event by 1 to 4 weeks. C. trachomatis is thought to be responsible for up to 10% of cases of early inflammatory arthritis. It develops in 1 to 3% of patients with chlamydial urethritis. The diagnosis is suggested by the detection of the involvement of at least one joint, symptoms of genitourinary infection, and the detection of Chlamydia on a genitourinary swabs or urine ligase chain reaction. Women may not have any urogenital manifestations at all. Only one third will have lower back pain, enthesitis, or radiographic sacroiliitis. In those with reactive arthritis secondary to chlamydia, the suggested treatment is a course of doxycycline.
NSAIDs, such as indomethacin or Naprosyn, are used in ankylosing spondylitis and Reiter's syndrome. NSAIDs alone can give some symptomatic improvement but won't treat the underlying cause. Systemic corticosteroids are reserved for severe disease flares. Slow-acting, antirheumatic drugs, such as sulfasalazine or methotrexate, should be considered when chronic peripheral arthritis, enthesitis, or spondylitis exists and is unresponsive to NSAIDs.
Record # 11
Question/Fact:
A 22-year-old man who is a recent immigrant from Pakistan comes to the emergency department because of a shock-like sensation in his left thigh on forward flexion. His left leg becomes fatigued easily. He has a fever and has been losing weight. He was treated for tuberculosis for a long time in his country but was noncompliant with the medications. Neurological examination demonstrates lower extremity paraparesis. An MRI of the spine reveals collapsed vertebrae at the level of T11 to L1. Which of the following is the most appropriate next step in his management?
(A) Start nafcillin
(B) Lumbar puncture
© Orthopedic consultation
(D) Bone scan
(E) Immediate radiotherapy
Answer:
© Orthopedic consultation
Explanation:
The clinical presentation and MRI findings are consistent with tuberculosis of the spine, or Pott's disease. The onset of symptoms is generally insidious and is often not even accompanied by fever. Tuberculosis usually involves the midthoracic spine. Anterior erosion of vertebral bodies causes collapse, resulting in kyphosis. Lumbar puncture is not needed, and in this case, it would be difficult due to distortion of the architecture of the vertebral body. Paraplegia is the most serious complication. In the presence of new paraparesis, immediate orthopedic consultation should be called for bone biopsy and possible fixation of the vertebrae. Bone scan will delay treatment, such as decompression of spinal cord, and adds little to the diagnosis because it will not substitute for a bone biopsy. Cultures of the bone can be done at the time of surgery. There is no evidence that this man has a malignant process, and immediate radiotherapy will not be appropriate at this time. The management of tuberculosis of the spine is with the same initial four-drug regimen used in pulmonary tuberculosis. The only major difference is that the duration of therapy should be extended to 12 months or longer.
Record # 12
Question/Fact:
A 65-year-old woman is admitted to the hospital on Friday night with an episode of squeezing, substernal chest pain that occurred while the patient was watching her favorite TV show. The pain lasted for twenty minutes and was not relieved by nitroglycerin. A dobutamine stress echocardiogram was done a month ago by her private physician, which showed posterior and lateral wall motion abnormalities. Her past medical history is significant for diabetes mellitus.
On arrival at the hospital, an EKG shows ST-segment depression in the lateral leads. She is started on aspirin, nitrates, beta-blockers, and intravenous unfractionated heparin. Three sets of cardiac enzymes are negative. A complete blood count shows a white cell count of 7,800/mm3, a hematocrit of 37%, and a platelet count of 180,000/mm3. The medications are continued, and she is transferred from the cardiac care unit on Sunday evening with plans for a coronary angiography the next day.
On Monday, the patient complains of pain in the right leg. The physical examination is unremarkable, except for moderate right-calf tenderness. The venous Duplex shows thrombosis of the right popliteal vein. Another complete blood count shows: WBC 9,900/mm3, hematocrit 38.8%; and platelets 45,000/mm3. The prothrombin time (PT) is 13.6 seconds, INR 1.0, and partial thromboplastin time (PTT) 68 seconds.
What is your next step in the management of this patient?
(A) Continue unfractionated heparin and start coumadin after the angiogram
(B) Switch unfractionated heparin to low-molecular-weight heparin
© Immediately stop heparin and remove heparin-coated catheters
(D) Corticosteroids
(E) Switch unfractionated heparin to lepirudin
Answer:
(E) Switch unfractionated heparin to lepirudin
Explanation:
This patient is suffering from heparin-induced thrombocytopenia (HIT) and also a deep venous thrombosis, which is most likely the result of this disorder. One to 3% of patients who receive unfractionated heparin will develop antibodies against platelets. All forms of heparin must be stopped when HIT occurs. You cannot just switch to low-molecular-weight heparin. Although low-molecular-weight heparin carries a much smaller risk of developing thrombocytopenia, 70% of the antibodies that develop will cross-react with low-molecular-weight heparin. Again, all heparins must be stopped because 30% of those with HIT will develop some form of thrombosis. Seventy-five percent of the time, the thrombi are venous, and only 25% are arterial. This patient has a thrombosis and therefore needs an alternate type of anticoagulation. Coumadin will not be effective rapidly enough, and the patient is also scheduled for angiography the following day.
Lepirudin is an analog of hirudin. These drugs are natural anticoagulants that inhibit thrombin and are derived from leeches. They do not cross-react with HIT-induced antibodies. Lepirudin can be monitored with the PTT. Danaparoid is a heparinoid that is no longer marketed in the United States.
Record # 13
Question/Fact:
A 35-year-old woman (gravida 1, para 0) presents to the emergency room at 32 weeks of pregnancy with complaints of progressive shortness of breath over the last week and paroxysmal nocturnal dyspnea for the last 3 weeks. The patient states that she recently started to use three pillows during sleep. The patient has a history of atrial fibrillation and uses digoxin for rate control. She got married two years ago and has been unable to conceive for more than one year. Her pulse is 120/min and irregular, and her blood pressure is 130/85 mm Hg. Physical examination reveals jugular venous distension, bibasilar lung crackles, a loud S1, an opening snap following S2, and a low-pitched diastolic murmur best heard in the left lateral decubitus position.
In the emergency department, the patient receives oxygen via nasal canula, furosemide 80 mg intravenously, and diltiazem 20 mg intravenously with no significant improvement in her symptoms. Echocardiography shows normal left ventricular systolic function with a mitral valve area of 0.9 cm2.
Which of the following is the most effective therapy in her management?
(A) Initiate therapy with lisinopril
(B) Start metoprolol
© Balloon valvuloplasty
(D) Cesarean section
(E) Increase the dose of digoxin
Answer:
© Balloon valvuloplasty
Explanation:
Almost all cases of mitral stenosis in adults are secondary to rheumatic heart disease. Most cases of mitral stenosis occur in women. Mitral valve stenosis impedes left ventricular filling, thereby increasing left atrial pressure as a pressure gradient develops across the mitral valve. Elevated left atrial pressure is referred to the lungs, where it produces pulmonary congestion. In mitral stenosis, the symptoms of left ventricular failure (dyspnea on exertion, orthopnea, and paroxysmal nocturnal dyspnea) are usually not due to left ventricular dysfunction, but rather to the mitral stenosis itself preventing the flow of blood out of the lungs.
The physiologic changes imposed by pregnancy can cause cardiac decompensation in any patient with a significant cardiac abnormality, especially in patients with mitral and aortic stenosis. This is because of the 50% rise in plasma volume routinely occurring during pregnancy. Symptoms of mitral stenosis become more severe during pregnancy because of the increase in diastolic flow and the rate-related shortening of the duration of diastole. Left atrial pressure rises, and dyspnea or pulmonary edema can occur in previously asymptomatic individuals. Atrial fibrillation also often leads to acute decompensation because of a shortened diastolic filling time as well.
Despite the appropriate use of diuretics to relieve pulmonary edema and the use of intravenous diltiazem to slow down the ventricular rate, in this case with atrial fibrillation, both the mother and the fetus are at high risk of injury because of pulmonary edema and hypoxemia. Balloon valvuloplasty is the most direct and effective form of therapy in this critical situation. Ending the pregnancy at 32 weeks' gestation is more hazardous to the fetus than the radiation exposure during the procedure. ACE inhibitors will not help, and besides that, they are contraindicated in pregnancy because of their teratogenic effects.
Record # 14
Question/Fact:
A 57-year-old man comes to the office with three days of cough and sputum production. Physical examination reveals rales at the left base. The chest x-ray shows a left lower lobe infiltrate. His respiratory rate is 22/min, and his oral temperature is 102 F. The pulse oximeter shows a 94% saturation on room air. How would you manage this patient?
(A) Wait for results of Gram stain and sputum culture
(B) Oral amoxicillin
© Oral gatifloxacin
(D) Intravenous cefuroxime
(E) Oral amoxicillin/clavulanic acid
Answer:
© Oral gatifloxacin
Explanation:
This patient can be safely treated as an outpatient. His respiratory rate, although raised at 22/min, is still <30/min. He is only mildly hypoxic. He is relatively young and has no other comorbid conditions, such as renal, liver, lung, or heart disease or cancer. Fever alone is not a reason to hospitalize someone. Sputum Gram stain and culture have a <50% sensitivity in the detection of a specific organism. Even if they were 100% sensitive, there would still be no reason to defer therapy until the results were obtained. Oral amoxicillin will not cover Legionella, Chlamydia, and Mycoplasma. It is also not as effective against pneumococcus as the newer fluoroquinolones, even when combined with clavulanic acid. Standard therapy for the outpatient management of community-acquired pneumonia is either with a macrolide or a new fluoroquinolone, such as levofloxacin, moxifloxacin, or gatifloxacin.
Record # 15
Question/Fact:
A 56-year-old man comes to the office for evaluation of his diabetes. He is well maintained on a sulfonylurea and metformin. He is a nonsmoker and has no history of hypertension or coronary disease. His father is the Jedi master Yoda who lived to be 900 years old without coronary disease. His glucose level today in the office is 135 mg/dL (normal 60-110 mg/dL), hemoglobin A1C 7.2% (normal 4-7%), and his LDL is 145 mg/dL. What is the most appropriate management of this patient?
(A) No further therapy indicated
(B) Step 2 diet, restricting lipid intake alone
© Niacin
(D) Statins
Answer:
(D) Statins
Explanation:
The presence of diabetes is considered the equivalent of coronary disease in the management of hyperlipidemia. Diabetes is such a strong risk for coronary disease and myocardial infarction that drug therapy should be started if the LDL is >130 mg/dL, with the goal of driving it under 100 mg/dL. It is optional even to start lipid-lowering drug therapy even with an LDL between 100-130 mg/dL. Niacin is not ideal in the management of those with diabetes because it impairs the ability to control glucose levels. Beside its effects on glucose levels, the best evidence for an improvement in mortality is with the use of the statins.
Record # 16
Question/Fact:
A 69-year-old man with a prolonged history of hypertension and diabetes mellitus is brought to the emergency department by his daughter with right lower extremity weakness and slurred speech. These symptoms developed suddenly over the last two hours. One month ago, he underwent laparoscopic cholecystectomy. He had a severe hematuria six weeks ago. Upon arrival, his blood pressure is 160/90 mm Hg, and his heart rate is 72/min. Neurological examination reveals right lower extremity weakness with 3/5 motor strength and decreased sensation in the same leg. Neck examination reveals a mild carotid bruit on the left. The EKG shows normal sinus rhythm. A CT scan of the head is normal. All laboratory tests are normal. Which of the following is most appropriate at this time?
(A) Aspirin 325 mg daily
(B) Aspirin 325 daily and dipyridamole 200 mg twice a day
© Coumadin
(D) tPA intravenously
(E) Heparin intravenously
Answer:
(D) tPA intravenously
Explanation:
This patient is evaluated within three hours after the onset of his neurological deficit, and he should receive tPA. It is the only approved medication for the treatment of acute ischemic stroke. It is effective in reducing neurological deficits in selected patients without CT-scan evidence of intracranial hemorrhage when administered within three hours of the onset of symptoms. Administration of tPA after three hours has not been proven to be effective or safe. A laparoscopic cholecystectomy a month ago and hematuria alone are not contraindications to the use of tPA. They are relatively minor risks for an increased risk of bleeding. Although the blood pressure is elevated in this case, it is still <185/110 mm Hg. Contraindications to the use of thrombolytics are a recent hemorrhage, an increased risk of hemorrhage, a recent myocardial infarction, an arterial puncture at a noncompressible site within the preceding seven days, major surgery within fourteen days, a systolic blood pressure above 185 mm Hg, or a diastolic pressure above 110 mm Hg. Gastrointestinal or severe urinary tract hemorrhage is also a contraindication to thrombolytic therapy. Heparin has no role in the management of patients with completed stroke, except when there is a cardiac source of embolization, such as a thrombus or atrial fibrillation. Treatment is then started with heparin and warfarin. There is an increased risk of early and serious intracranial and extracranial bleeding, and no long-term neurological benefit with heparin treatment for patients with acute ischemic stroke.
Record # 17
Question/Fact:
In determining fulminant hepatic failure, which of the following parameters should be closely monitored because it is best for predicting progression to failure?
(A) AST and ALT
(B) Alkaline phosphate
© Bilirubin
(D) Prothrombin time
(E) White blood cell count
Answer:
(D) Prothrombin time
Explanation:
In patients with severe hepatitis, the synthetic function of the liver most accurately predicts the mortality. The prothrombin time is based on the hepatic synthesis of factors 2, 5, 7, 9, 10, and fibrinogen. Thus, choice D is the correct answer.
Record # 18
Question/Fact:
A 35-year-old woman presents to your office complaining of a cough. She has a history of hyperthyroidism, which has been well controlled with propylthiouracil for the past 6 months. The cough has been getting progressively worse over the past week. She did not measure her temperature but does not complain of chills or night sweats. She has had no nausea, vomiting, or diarrhea. She is a nonsmoker. Her temperature is 101 F, with a blood pressure of 120/80 mm Hg, a heart rate of 88/min, and a respiratory rate of 22/min. Her oxygen saturation on room air is 92%. She has a slightly enlarged thyroid with no nodules or bruits. Her lung examination shows diffuse crackles bilaterally. The heart examination is normal, but a chest x-ray shows bilateral lobar consolidation. Which of the following would be the most appropriate for this patient?
(A) Thyroid-stimulating hormone (TSH)
(B) Chest CT scan
© CBC with manual differential, pan-cultures, and broad-spectrum antibiotics
(D) Bone marrow biopsy
(E) TSH-receptor antibody titers
Answer:
© CBC with manual differential, pan-cultures, and broad-spectrum antibiotics
Explanation:
This patient's hyperthyroidism is being treated with propylthiouracil (PTU); therefore, the patient is at risk for PTU-induced agranulocytosis. Any sign of illness in this patient must be quickly investigated for agranulocytosis. CBC would be the most appropriate initial test to see her neutrophil count. A patient with agranulocytosis may not show many systemic signs of infection. Similar to patients with neutropenia from cancer, a fever alone may be an indication to start immediate antibiotics. Due to a lack of neutrophils, the patient is at a high risk of bacterial and fungal infection. Although it is always appropriate to monitor the effect on the thyroid hormone levels, this is not as urgent as checking for the most life-threatening toxicity of PTU. A chest CT scan may be helpful later for evaluation of the abnormal lung examination and chest x-ray, but it would not be performed first. Bone marrow biopsy is never appropriate before checking the CBC.
Record # 19
Question/Fact:
A young man is found by the security guards outside the doors of the emergency room screaming and agitated. His blood pressure is 145/100 mm Hg, with a heart rate of 123/min, a temperature of 101.0 F, and a respiratory rate of 22/min. During the examination, the patient begins having a generalized seizure with urinary and fecal incontinence. The patient is intubated for airway protection, and the physical examination is continued. His pupils are dilated. His sodium is 143 mEq/L, with a creatinine of 0.9 mg/dL and a glucose of 126 mg/dL. Which of the following would be most useful for this patient?
(A) Propranolol
(B) Benzoylecgonine in the urine
© N-acetylcysteine
(D) Lumbar puncture and flumazenil
Answer:
(B) Benzoylecgonine in the urine
Explanation:
This patient's presentation is consistent with signs of cocaine intoxication. These patients can present with anxiety, tachycardia, hypertension, dilated pupils, agitation, muscular hyperactivity, and psychosis. The sustained hypertension may lead to intracranial hemorrhage, aortic dissection, or myocardial infarctions. The hypertension should not be treated with a pure beta-blocker alone because it may result in a paradoxical worsening of the hypertension due to an unopposed alpha-adrenergic effect. It should be treated with a vasodilatator such as nitroprusside or a combined alpha/beta agent, such as labetalol. N-acetylcysteine should be given for acetaminophen intoxication. Listeria infection is unlikely: This patient has no risk factors for it. Blood toxicology is not as specific as urine in most cases of qualitative drug screening, although it is better for qualitative tests. In cocaine intoxication, either cocaine or one of the metabolites, such as benzoylecgonine, are positive. This test is useful in this patient to establish a specific diagnosis. We have not yet truly proven why he is agitated.
Record # 20
Question/Fact:
A 45-year-old woman recently emigrated from Israel presents to the clinic with nasal discharge, weakness, nausea and vomiting, and decreased appetite for 3 weeks. She has had a low-grade temperature for a few days and has decided to come to the clinic today for antibiotics. On further questioning, she has had mild, diffuse, abdominal pain for the last month and has lost 5 lb as a result of having no appetite. She states that the abdominal pain is relieved by lying down and increases on exertion. She denies use of alcohol and smokes 1 pack of cigarettes per day but has had no desire for cigarettes over the past week. On physical examination, she is a healthy-appearing woman. Her temperature is 39.5 F, blood pressure is 135/75 mm Hg, heart rate is 78/min, and respirations are 18/min. She is anicteric and in no acute distress. There is some cervical lymphadenopathy, and the abdomen is mildly tender in the right upper quadrant.
Laboratory tests reveal the following: WBC 5,600/mm3, hemoglobin 10.8 mg/dL, hematocrit 38,8%, platelets 274,000/mm3, PT 28 seconds, INR 3.8, PTT 31 seconds, sodium 138 mEq/L, potassium 4.0 mEq/L, chloride 112 mEq/L, CO2 22 mEq/L, BUN 14 mg/dL, creatinine 0.8 mg/dL, and calcium 105 mg/dL. ALT is 382 U/L, AST is 327 U/L, and alkaline phosphatase is 121 U/L. Testing for hepatitis-C antibody is positive, hepatitis B e antigen (HbeAG) is negative, hepatis B e antibody (HbeAb) is negative, hepatitis B surface antigen (HbsAG) is negative, and hepatitis C virus (HCV) RNA is 580,000. What is the best treatment for this patient?
(A) Interferon-a-2b for six months
(B) Hepatitis B immunoglobulin (Ig) followed by hepatitis B virus (HBV) vaccine series
© Corticosteroids with morphine sulfate for pain relief
(D) Lamivudine
(E) Observation
Answer:
(A) Interferon-a-2b for six months
Explanation:
In patients with acute hepatitis C, early initiation of treatment with interferon will prevent the development of chronic hepatitis C in over 90% of persons. Lamivudine treats hepatitis e antigen-positive patients. Hepatitis B immunoglobulin (HBIG) is to prevent infection after an exposure to hepatitis-B surface-antigen-positive patients.
Record # 21
Question/Fact:
A 28-year-old female develops severe uterine bleeding with coagulation profile abnormalities eight hours after a successful delivery. She does not have any prior medical history, and the pregnancy was uncomplicated. She does not take any medications at home, except for multivitamins. The family history is unremarkable for any bleeding disorders. She has had tooth extractions in the past with no increase in bleeding.
On physical examination the patient presents as an anxious, nervous female, that looks her stated age. Her temperature is 97.8 F, blood pressure is 110/50 mm Hg, heart rate is 90/min, and the respiratory rate is 16/min. Her skin is pale. The uterus is enlarged, soft, and mildly painful on palpation. There are no external tears on vaginal exam. The amount of bleeding increases during palpation of the uterus.
Laboratory studies show the following results:
WBC 5,800/mm3; hemoglobin 9.8 g/dL; hematocrit 32.1 %, platelets 188,000/mm3; PT 12.4 seconds, INR 0.9, PTT 56 seconds. Bleeding time is normal. Fibrinogen 330 mg/mL; factor VIII: C level 22%.
The bleeding started three hours ago. During this time, the patient has received two units of packed red blood cells and six units of fresh frozen plasma (FFP), but the PTT remains elevated, and the bleeding still continues. Which test would be most useful in this situation?
(A) Von Willebrand's factor level
(B) Antiphospholipid antibody
© Russell viper venom (RVV) time
(D) PTT 1:1 mixing test
(E) Fibrin degradation products
Answer:
(D) PTT 1:1 mixing test
Explanation:
This patient developed factor VIII antibodies, which may happen postpartum or even sometimes without an obvious underlying cause. This can also occur in 15% of patients with factor VIII hemophilia, who have received infusions of fresh frozen plasma (FFP) or factor VIII replacement. In this disorder, the bleeding is usually severe, there is a decreased factor VIII level, and the PTT is prolonged. The fibrinogen level, PTT, and platelet count are not affected.
A plasma mixing test will show the presence of an inhibitor by the failure of normal plasma to correct the prolonged PTT. This test may require incubation for 2 to 4 hours. Factor VIII coagulant levels are low, which should not happen in von Willebrand's disease.
Hemophilia A is extremely unlikely in a woman because she would have to be homozygous recessive for the X-linked disorder. Factor VIII antibodies should be suspected in any patient with acquired severe bleeding and a prolonged PTT. The diagnosis is confirmed by mixing tests and by a failure of factor VIII concentrates to raise factor VIII:C levels.
Von Willebrand's disease is associated with mild mucosal bleeding. The measurement of von Willebrand's factor level will help you to distinguish between hemophilia A and von Willebrand's disease but won't explain why the coagulation profile was not corrected by transfusions of FFP.
Lupus anticoagulant is not associated with bleeding, unless a second disorder, such as thrombocytopenia or hypothrombinemia is present. Most commonly, it presents with thrombosis. Lupus anticoagulant also gives a prolonged PTT, and the mixing study will also fail to correct.
The Russell venom viper test is a more sensitive assay to demonstrate the presence of a lupus anticoagulant.
An antiphospholipid antibody is usually positive. Anticardiolipins are a related antiphospholipid antibody that can be detected by a separate assay.
Fibrin degradation products are elevated in DIC, which also presents with hypofibrinogenemia. D-dimer is the most sensitive of the fibrin-degradation products. The patient is usually seriously ill and has a low platelet count and elevation of the PT, as well as PTT. Bleeding may occur at any site, but spontaneous bleeding and oozing at venipuncture sites are important clues to the diagnosis.
Record # 22
Question/Fact:
A 35-year-old woman presents to the office with complaints of intermittent diarrhea over the past few weeks. She has lost 15 to 20 lb recently, despite a healthy appetite and normal food intake. She states that she frequently has loose, bulky, and foul-smelling stools. She denies any abdominal pain, the use of alcohol, and has no recent travel history. Past medical history is significant for insulin-dependent diabetes mellitus, diagnosed at age 14. At age 20, a perforated pyloric channel ulcer was treated surgically by a Roux en Y. Besides insulin, the patient takes no other medications.
On physical examination the vital signs are normal. She is a thin, pale-appearing woman. Her abdomen is soft and nontender with no hepatosplenomegaly. Her stool is negative for occult blood. She has diminished sensation over the bilateral lower extremities. Laboratory tests show: white blood cells: 7,500/mm3, hemoglobin 9.1 mg/dL, hematocrit 30%, platelets 450,000/mm3, mean corpuscular volume 105 μm3, vitamin B12 92 pg/mL (normal 330-1,025 pg/mL), and albumin 2.5 g/dL. The patient undergoes a 72-hour stool collection and excretes 21 grams of fat/24 hours (elevated). Stool culture is negative for parasites. What can the leading cause of malabsorption in this patient be attributed to?
(A) Pancreatic exocrine insufficiency
(B) Eosinophilic gastroenteritis
© Bacterial overgrowth secondary to Roux en Y surgery and diabetic enteropathy
(D) Pernicious anemia
(E) Crohn's disease
Answer:
© Bacterial overgrowth secondary to Roux en Y surgery and diabetic enteropathy
Explanation:
Bacterial overgrowth can cause diarrhea and malabsorption. Both a Roux en Y limb and diabetic enteropathy can result in bacterial overgrowth. The small intestine normally contains a small number of bacteria. Bacterial overgrowth results in malabsorption secondary to bacterial deconjugation of bile salts, leading to inadequate micelle formation. This will ultimately result in decreased fat absorption with steatorrhea. Microbes and bacteria uptake nutrients, thereby reducing absorption of vitamin B12 and carbohydrates. The proliferation of bacteria directly damages intestinal epithelial cells, as well as the brush border, impairing protein absorption. Passage of malabsorbed bile acids and carbohydrates into the colon leads to an osmotic and secretory diarrhea.
Record # 23
Question/Fact:
A 70-year-old woman has been brought to the emergency department for shortness of breath, cough, and lethargy for one day. The patient is confused. The daughter denies any problem of this type with the patient in the past, but she says cancerous polyps were found last year on colonoscopy. There has been progressive confusion and deterioration in her mental status over several years. On physical examination, the patient was found to be confused and has a temperature of 101 F, a blood pressure of 85/60 mm Hg, a pulse of 120/min, and a respiratory rate of 28/min. The chest examination shows decreased breath sounds with dullness to percussion on the right side at the base. The cardiac examination is normal. Laboratory studies reveal: white cell count 12,000/mm3, hematocrit 28%, platelets 400,000/mm3, sodium 135 mEq/L, bicarbonate 20 mEq/L, BUN 60 mg/dL, creatinine 3 mg/dL, and glucose 110 mg/dL. Urinalysis is positive for protein. Chest x-ray shows a right lower lobe infiltrate. Which of the following is correct about this patient?
(A) She has an approximately 30% chance to die with in 30 days
(B) Bronchoscopy is required
© The chance for Streptococcus pneumonia to be isolated is 80%
(D) Start ciprofloxacin
(E) Start vancomycin
Answer:
(A) She has an approximately 30% chance to die with in 30 days
Explanation:
The Pneumonia Outcome Research Team (PORT) scoring system is used to assess the risk of mortality on the basis of 19 clinical variables. The system stratifies patients into five mortality risk classes. This patient, with a score of >130, falls within the risk class V, which has a mortality risk between 27 and 31%. The following are the clinical variables for this patient and their scoring:
Age 70 (women: age - 10) = 60
Renal disease = 10
Hematocrit <30% = 10
Pleural effusion = 10
BUN >30 mg/dL = 20
Systolic pressure <90 mm Hg = 20
Neoplasm = 30
Total = 160
Patients with this class of mortality risk definitely need hospitalization. Streptococcus pneumoniae is the most common organism to be isolated in adults, but it is isolated in far less than 80% of cases. Prospective studies fail to identify a specific microbiologic cause of community-acquired pneumonia (CAP) in >50% of cases. Sputum Gram stain and culture should be done on all patients who are hospitalized. Bronchoscopy is not necessary unless the patient is severely ill, and sputum analysis fails to identify a specific causative organism. Ciprofloxacin is not an appropriate choice of medication for CAP; it has inadequate pneumococcal coverage. Vancomycin is used in pneumonia only if the causative organism has been definitely identified as penicillin-resistant pneumococcus. The other criteria for a serious pneumonia are: the presence of liver or heart disease, a pulse of >125/min, a sodium of <130 mEq/L, a glucose of >250 mEq/L, a pO2 of <60 mm Hg, a fever >40 C, and confusion.
Record # 24
Question/Fact:
A 28-year-old man with a history of renal insufficiency comes to your office with the gradual onset of mild lower back pain that has been radiating down to his thighs over the last two months. He also complains of bilateral shoulder and knee pain that improves with exercise. The patient states that his back is slightly stiff in the morning and that this stiffness is worsened by rest and relieved when he walks. He has never had any back pain before. On physical examination, he is afebrile. There is no local lower back tenderness, and he has a minimally decreased range of motion in the lumbar part of the spine. His rheumatoid factor is negative, and the ESR is 40 mm/h. Plain x-rays of the spine and pelvis are normal. Which of the following is the most appropriate management at this time?
(A) Hydroxychloroquine
(B) Prednisone
© Indomethacin
(D) Celecoxib
(E) Physical therapy
Answer:
(E) Physical therapy
Explanation:
This patient presents with what is most likely ankylosing spondylitis (AS). This is a chronic inflammatory disease of the joints of the axial skeleton, manifested by pain and progressive stiffness of the spine. He has had this pain for only two months, and the MRI will most likely not show any changes in the sacroiliac joints. He has very mild disease and no evidence as of yet of an anatomic abnormality. In fact, he is still missing many of the firm diagnostic criteria for AS, such as >3 months of symptoms, limited thoracic motion, iritis, and radiological evidence of sacroiliitis. Eventually, erosions and sclerosis of sacroiliac joints will become evident on radiographs. The term "bamboo spine" has been used to describe the late radiographic appearance of the spinal column. This patient has a history of renal insufficiency, and NSAIDs or COX-2 inhibitors may worsen his renal function and are thus contraindicated in this case. He now has only mild lower back pain with slight stiffness and will benefit from physical therapy, which might prevent axial skeleton deformity.
The onset of AS is usually gradual with intermittent bouts of back pain that may radiate down the thighs. The disease progresses in a cephalad direction, and back motion becomes progressively more limited. Transient acute arthritis of peripheral joints occurs in approximately 50% of cases, and permanent changes in the peripheral joints are seen in about 25%. This is most common of the hips, shoulders, and knees.
Record # 25
Question/Fact:
A 30-year-old woman in her thirtieth week of pregnancy comes in for her monthly evaluation by her obstetrician. As a part of her routine evaluation, she provides a urine specimen to the nurse. She has urinary frequency of 8 to 10 trips to the bathroom per day. She denies dysuria, hematuria, or fever. Her temperature is 99 F, with a pulse of 90/min and a blood pressure of 110/70 mm Hg. The examination reveals a gravid uterus compatible with 30 weeks of gestation. Her genital examination reveals no discharge or erythema. The urinalysis reveals 10 to 25 white cells/hpf with numerous bacteria but no red cells. What is your next step at this time?
(A) Do nothing
(B) Trimethoprim/sulfamethoxazole
© Ampicillin
(D) Gatifloxacin
(E) Renal ultrasound
(F) Ciprofloxacin
Answer:
© Ampicillin
Explanation:
This patient is presenting with a urinary tract infection (UTI) during pregnancy. Though minimally symptomatic at this time, it is important to treat all urinary infections during pregnancy. There is a 20 to 40% risk of developing pyelonephritis if untreated. A diagnostic study, such as a renal ultrasound, is not appropriate at this time. Of the antibiotics listed, only ampicillin is appropriate. Nitrofurantoin or cephalosporins, such as cephalexin, are safe to use in pregnancy but are not listed in the answer choices. Sulfa-based drugs can predispose to hyperbilirubinemia and kernicterus by interfering with bilirubin binding and should be avoided in the later trimesters. Fluoroquinolones, like gatifloxacin and ciprofloxacin, are potentially teratogenic upon the skeletal system and cartilage of the fetus.
Record # 26
Question/Fact:
A 78-year-old man with a history of coronary artery disease, congestive heart failure (CHF), and hyperlipidemia was admitted to CCU three days ago with a diagnosis of non-Q-wave myocardial infarction (MI). He was transferred to a regular floor yesterday after he was stabilized.
His current medications include aspirin, metoprolol 25 orally twice a day, nitroglycerin, furosemide 40 mg orally twice a day, and simvastatin. Physical examination shows a pulse of 82/min, a respiratory rate of 16/min, and a blood pressure of 112/62 mm Hg. There are minimal bibasilar crackles on lung examination, an S4 gallop on cardiac examination, and a trace edema in the extremities. Echocardiogram shows decreased left ventricular systolic function. You start him on captopril 6.25 mg every eight hours and double the dose with each additional dose until you reach the minimal effective dose of 50 mg three times a day. The following day, the nurse informs you that his blood pressure dropped to 95/49 mm Hg, with a pulse of 94/min, and she is hesitant to give any antihypertensive medications. What would be the most appropriate response?
(A) Discontinue metoprolol
(B) Discontinue captopril
© Reduce the dose of furosemide
(D) No intervention because his blood pressure drop is transient
(E) Hold all medications
Answer:
© Reduce the dose of furosemide
Explanation:
ACE inhibitors such as captopril have become standard therapy for CHF because they have been shown to decrease mortality. They should be started with small doses and titrated up as tolerated because of a possible hypotensive effect. The final dosage should be 50 mg orally every 8 hours. This is the minimum needed to achieve the needed effect on relieving afterload. Remember, however, that there is virtually no reason to use a cumbersome three-times-a-day medication such as captopril for an outpatient when drugs such as ramipril, quinapril, lisinopril, and fosinopril can be used once a day and with far greater adherence.
This patient developed his hypotensive episode a full day after being on a higher dose of the ACE inhibitor. The hypotensive episode may therefore not be directly related to just the use of the ACE inhibitor. The diuretic dose may need downward adjustment or be withheld for 24 hours. Besides having only minimal signs of fluid overload, the question is making sure you know that it is more important to first remove drugs that don't have a definite effect on lowering mortality. In addition, reducing the dose of Lasix to 20 or 40 mg once a day will not result in any harm to the patient.
Record # 27
Question/Fact:
A 45-year-old man has had dysphagia of increasing severity over the past year. He has recently lost 5 lb. The upper endoscopy shows distal erythema of the esophageal mucosa and resistance to the passage of the endoscope at the esophagogastric junction. No anatomical lesion is seen. Esophageal motility shows lack of peristalsis in the body of the esophagus and a high-pressure lower esophageal sphincter with incomplete relaxation with swallowing. Which of the following treatments would NOT be appropriate for this patient?
(A) Pneumatic dilatation
(B) Botulinum toxin injection
© Surgical myotomy
(D) Anticholinergic agents
(E) Calcium-channel blockers
Answer:
(D) Anticholinergic agents
Explanation:
Achalasia is an idiopathic disorder characterized by disturbed esophageal motility and high pressure of the lower esophageal sphincter, with incomplete relaxation during normal swallowing. Most patients with achalasia are treated with pneumatic dilatation. Botulinum toxin and calcium-channel blockers can be attempted with some success. The surgical Heller myotomy is the most effective surgical technique. Anticholinergic agents only exacerbate the disease.
Record # 28
Question/Fact:
A 72-year-old man is admitted to the hospital from a nursing home for a pressure ulcer of his ankle. The x-ray of the foot shows bone destruction consistent with osteomyelitis. A biopsy of the bone reveals Escherichia coli that is sensitive to every antibiotic tested. What is the most appropriate therapy?
(A) Intravenous piperacillin-tazobactam for six weeks
(B) Intravenous ampicillin-sulbactam for six weeks
© Oral amoxicillin-clavulanic acid for six weeks
(D) Oral ciprofloxacin for six weeks
(E) Intravenous ceftazidime for six weeks
Answer:
(D) Oral ciprofloxacin for six weeks
Explanation:
Although all of the medications listed will be effective for a sensitive E. coli, the most convenient therapy is oral ciprofloxacin. Oral quinolones, specifically ciprofloxacin, are equal in efficacy to intravenous therapy.
Record # 29
Question/Fact:
A 50-year-old man is brought in by an ambulance to the emergency department because of increased shortness of breath for the past two weeks. He feels short of breath on exertion for the last two years, uses at least two pillows at night, and denies chest pain or palpitations. He has no history of ischemic heart disease. He is not compliant with his medications and forgets to take his "water pills." He has five vodka martinis every night. The patient has been smoking one pack of cigarettes a day for the past 30 years. Last month he was treated in another hospital for alcohol withdrawal symptoms.
On physical examination, the patient is lying in bed and is slightly short of breath. His temperature is 97.0 F, heart rate is 78/min, respiratory rate is 22/min, and blood pressure is 150/80 mm Hg. The neck veins are distended. There is cardiomegaly and an S3 gallop. On lung auscultation, there are crackles at both bases. The liver edge is palpated 2 cm below the right costal margin. There is 1+ bilateral leg edema.
EKG shows low QRS voltage, nonspecific ST-segment and T changes. The chest x-ray shows cardiomegaly and mild pulmonary congestion. Left ventricular dilation is found by echocardiogram.
What is your choice of therapy at this time?
(A) Captopril, furosemide, beta-blockers
(B) Losartan, furosemide, coumadin
© Captopril, spironolactone, digoxin
(D) Captopril, furosemide, digoxin, coumadin
Answer:
(A) Captopril, furosemide, beta-blockers
Explanation:
This patient presents with dilated cardiomyopathy and displays signs of biventricular heart failure. Chronic alcohol abuse is one of the most frequent causes of dilated cardiomyopathy. The management is similar to that of congestive heart failure related to ischemia. The offending agent should be discontinued. Initial treatment usually consists of diuretics, ACE inhibitors, and beta-blockers. The addition of digoxin depends of presence of decreased left ventricular function and the persistence of symptoms despite the use of ACE inhibitors, diuretics, and beta-blockers. Chronic anticoagulation must be considered but should only be used if there were evidence of thrombosis. In addition, coumadin should be used with extreme caution in an alcoholic. Angiotensin-receptor blockers are indicated when patients cannot tolerate ACE inhibitors because of adverse effects, such as a cough.
Record # 30
Question/Fact:
A 68-year-old man with a history of hypertension is brought to your office with complaints of progressive memory loss and poor concentration over the last four months. According to the patient's wife, he has become forgetful, irritable, and emotionally labile. He is apathetic and has little spontaneous speech. Recently, the patient developed urinary incontinence and gait impairment. He has to take very short steps to walk; however, there is no shuffling gait. His funduscopic examination is normal. There is mild bradykinesia but no tremor or rigidity of the extremities. Lumbar puncture is performed in the office and led to an improved gait. Which of the following is the most appropriate management for this patient?
(A) Ventriculoperitoneal shunting
(B) Bromocriptine
© Aspirin
(D) Donepezil
(E) Penicillin
Answer:
(A) Ventriculoperitoneal shunting
Explanation:
This patient presents with normal-pressure hydrocephalus (NPH). NPH should be considered in mildly demented patients with gait disturbances and urinary incontinence. Mild, generalized slowness of movement and thought are frequently present in NPH and may be due to excessive cerebrospinal-fluid production or insufficient absorption. Large-volume lumbar puncture can lead to an improvement in the gait. Patients with NPH are more likely to benefit from ventriculoperitoneal shunting if there has been a demonstrated improvement in symptoms after a lumbar puncture. The lumbar puncture is not absolutely essential. If a patient has all the classic symptoms of NPH, you can go straight to ventriculoperitoneal shunting.
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