Practice Exam 1
Practice Exam 1
Practice Exam 1
lower calves and feet or forearms and hands because this disorder
primarily affects the distal vessels. Hand examination can reveal severe
digital ischemia, trophic nail changes, ulceration, and gangrene at the tips
of the fingers. Brachial and popliteal pulses are usually present, but radial,
ulnar, and/or tibial pulses may be absent. Smooth, tapering, segmental
lesions in the distal vessels are present on angiography. The diagnosis can
be confirmed by excisional biopsy of an involved vessel. There is no
specific treatment, except abstention from tobacco. The prognosis is worse
in those who continue to smoke, but results are relatively good in those
who stop. C-ANCA antibodies are usually found in Wegener's
granulomatosis. Arterial bypass may be indicated in disease confined to
larger vessels. The hand abnormalities effectively exclude peripheral
vascular disease. If these measures fail, amputation may be required.
Cyclophosphamide and prednisone do not help. Again, the management is
to stop smoking.
Topic:
Rheumatology
Record # 2
Question/Fact:
Record # 3
Question/Fact:
(C) Anticoagulation
Explanation:
Record # 4
Question/Fact:
Record # 5
Question/Fact:
(D) Ethanol
(E) Valium
Answer:
This patient most likely is intoxicated with valproic acid. This drug is widely
used in the management of seizure and mood disorders. Valproic-acid
intoxication produces a unique syndrome consisting of hypernatremia,
metabolic acidosis, hypocalcemia, elevated serum ammonia, and mild liver
aminotransferase elevation. Hypoglycemia may occur as a result of hepatic
metabolic dysfunction. Coma with small pupils may be seen, and this can
mimic opioid poisoning. Encephalopathy and cerebral edema can occur.
Phenytoin and carbamazepine are also commonly used antiseizure
medications. Phenytoin intoxication can occur with only slightly increased
doses. The overdose syndrome is usually mild. The most common
manifestations are ataxia, nystagmus, and drowsiness. Hepatic
encephalopathy would be unusual. Choreoathetoid movements are
occasionally seen. Carbamazepine is a first-line agent for temporal lobe
epilepsy, as well as trigeminal neuralgia. Intoxication causes drowsiness,
stupor, coma, or seizures. However, dilated pupils and tachycardia are
more common.
Signs of ethanol intoxication are similar to the signs of anticonvulsant
medication. In addition, it causes a high osmolar gap. Valium is an unlikely
cause of intoxication because this patient's blood benzodiazepine levels
are negative.
Topic:
Poisoning
Record # 6
Question/Fact:
Record # 7
Question/Fact:
Gastroenterology
Record # 8
Question/Fact:
(C) Plasmapheresis
Explanation:
Record # 9
Question/Fact:
Record # 10
Question/Fact:
for 7 days would be appropriate treatment if this were just a UTI. Therapy
for one week is not long enough to clear chronic bacterial prostatitis. Most
antibiotics don't have good penetration into the prostate, and it takes at
least four weeks of therapy with ciprofloxacin to clear the infection.
Ciprofloxacin and azithromycin for a single dose would be the treatment for
urethritis. This patient does have a urethral discharge, which may be
confused with urethritis. However, since the discharge is extruded only on
palpation of the prostate, this strongly suggests that the prostate is the
source of infection. Cystoscopy would be useful in a patient with recurrent
UTIs in whom you suspected a structural malformation of the genitourinary
tract. This patient's UTIs are originating from his chronically infected
prostate. Trimethoprim/sulfamethoxazole for 12 weeks is an acceptable
alternative for treating chronic prostatitis.
Topic:
Infectious Diseases
Record # 11
Question/Fact:
A 29-year old man comes to your office for a routine visit. His
only complaint is leg pain after walking a three-block distance.
He states that six months ago he was able to walk a longer
distance without having to stop. His father died of a heart attack
at the age of 44. His mother had diabetes mellitus, and she too
died of a heart attack at the age of 47. His older brother, who is
now 35 years old, had a stroke and underwent a carotid
endarterectomy last year.
The patient presents as a thin individual with a blood pressure
of 135/70 mm Hg and a heart rate of 78/min. Physical
examination findings are remarkable for the presence of multiple
xanthelasmas on the face, chest, and upper back. There is
bilateral, irregular, firm, and nodular thickening in the Achilles
tendons and extensor tendons of the hands. This patient's
medications include atorvastatin, gemfibrozil at maximum
doses, and niacin, which was added to the regimen six months
ago. He is maintaining a fat-free diet and exercises regularly.
Laboratory test results show: total cholesterol 815 mg/dL,
triglycerides 515 mg/dL, and HDL 55 mg/dL. The level of total
cholesterol has increased by 15% since the last visit.
What would you recommend to this patient?
(C) Plasmapheresis
Explanation:
Topic:
Cardiology
Record # 12
Question/Fact:
result is pending. What will you do while waiting for this result?
(A) Switch zidovudine and lamivudine to didanosine and
stavudine, and continue ritonavir
(B) Switch zidovudine, lamivudine, and ritonavir/lopinavir to
didanosine, stavudine, and indinavir, and stop simvastatin
(C) Continue all medications but stop simvastatin
(D) Continue zidovudine and lamivudine, and switch
ritonavir/lopinavir to efavirenz
(E) Switch to didanosine, stavudine, and efavirenz, and stop
simvastatin
Answer:
Record # 13
Question/Fact:
Record # 14
Question/Fact:
Record # 15
Question/Fact:
Answer:
Gout is a metabolic disease that most often occurs in men at middle age or
older. It rarely occurs in women until they are postmenopausal. The acute
gouty episode typically happens at night and is brought on by excessive
alcohol use, trauma, surgery, dietary excess, or glucocorticoid withdrawal.
The joint fluid aspirate appears cloudy because of the numerous white
cells. They typically range in number from 5,000 to 50,000/L. The cell
count in this range can be found in any kind of inflammatory arthritis, such
as gout, pseudogout, or rheumatoid arthritis. Crystal analysis is required to
distinguish them. Gout will have negatively birefringent, needle-shaped
crystals, whereas pseudogout will have weakly positive, rhomboid-shaped
crystals. Rheumatoid arthritis should have no crystals. Septic arthritis from
infection usually gives >50,000/L white cells in the synovial fluid. The
inflammatory process causes breakdown of hyaluronate in the joint fluid
and makes it become watery.
Topic:
Rheumatology
Record # 16
Question/Fact:
Record # 17
Question/Fact:
Record # 18
Question/Fact:
2-agonist, the exacerbations are affecting her daily activities, and they
recur at a frequency of more than twice per week, lasting days at a time.
Other parameters consistent with moderate persistent asthma are the
occurrence of nocturnal symptoms more than once per week. Her FEV 1
value of 68% is consistent with the criteria for the FEV 1 to fall between 60
and 80% of predicted, a reduced ratio of FEV1/FVC to <75%, and the
reversibility of airflow obstruction with bronchodilators of greater than
12%. A peak expiratory flow of less than 200 L/min indicates severe airflow
obstruction. During a mild asthma exacerbation, arterial blood gases may
be normal or reveal a respiratory alkalosis with an increased A-a gradient.
The combination of an increased PaCO2 and respiratory acidosis may
indicate respiratory failure, and the need for mechanical ventilation should
be considered.
There are four classifications of asthma:
1. Mild intermittent -- symptoms less than 2/week and FEV1 >80%
2. Mild persistent -- symptoms greater than 2/week but less than l/day
with FEV1 >80%
3. Moderate persistent -- daily symptoms greater than 2/week with FEV 1
>60 and <80%
4. Severe persistent -- continual symptoms with limited physical activity
and FEV1 <60%
Topic:
Pulmonary
Record # 19
Question/Fact:
Answer:
Record # 20
Question/Fact:
Explanation:
Record # 21
Question/Fact:
(B) Cardioversion
(C) Adenosine
(D) Insert a pacing catheter
(E) Procainamide
Answer:
(E) Procainamide
Explanation:
Record # 22
Question/Fact:
This woman most likely had an acute infection with Parvovirus B19, which
can cause a syndrome that mimics rheumatoid arthritis. Arthralgias from
Parvovirus B19 most commonly occur in woman in their thirties, whereas
rheumatoid arthritis occurs more commonly in older individuals.
Parvovirus B19 gives a polyarthritis that affects the proximal
interphalangeal joints of the hands, wrists, and knees. Arthralgias are
common. The diagnosis is mostly clinical when one gets a lacy,
maculopapular, truncal rash, along with malaise and a headache with little
fever. There is a laboratory test for serum IgM and IgG for Parvovirus B19.
Treatment is symptomatic, and most of these symptoms will resolve on
their own.
Methotrexate is an incorrect choice because the patient's symptoms are
too new to be considered rheumatoid arthritis, which is usually at least 6
weeks in duration and would be associated with a positive test for a
rheumatoid factor in 75% of patients. The ANA is also weakly and
nonspecifically positive in rheumatoid arthritis. Treatment for rheumatoid
arthritis involves NSAIDs accompanied with disease-modifying drugs, such
as hydroxychloroquine or sulfasalazine. There may be a need for using
three agents in very severe disease. Some of the other drugs that could be
Record # 23
Question/Fact:
In the obese patient with new-onset, type-2 diabetes mellitus, the initial
therapy of choice is metformin. Of all the oral hypoglycemics, metformin is
the only medication that results in weight loss and a more favorable lipid
profile. Metformin works primarily by suppression of hepatic
gluconeogenesis. As a result, this oral medication will never cause
Record # 24
Question/Fact:
(B) Diltiazem
Explanation:
This patient has a diastolic murmur and an opening snap consistent with
mitral stenosis. All the therapies described may be useful in the
management of mitral stenosis. As is often the case on board tests, all the
answers are partially correct. The initial step is to relieve this patient's
symptoms by controlling the heart rate. Ventricular filling is impaired by
mitral stenosis. The ventricle fills during diastole. The rapid rate of atrial
fibrillation shortens diastolic filling time and causes the symptoms. The
only therapy listed in the answer choices that controls heart rate is
diltiazem. Although furosemide will decompress the lungs, it will not slow
the heart rate. And although he may eventually need balloon valvotomy,
this would not be done before the heart rate has been controlled.
Coumadin will eventually be needed; worrying about a clot that might form
in a year is not as important as controlling the symptoms of dyspnea now.
It is unlikely that anything found on an echocardiogram will make you not
control the rate. The echocardiogram is needed but will not change the
initial management. Electrical cardioversion is not indicated for several
reasons. First, he is not acutely unstable. The dyspnea is on exertion, not
right now. Second, with mitral stenosis and what is surely an
accompanying left atrial dilation, he will probably revert back to atrial
fibrillation. The more abnormal the atrium is anatomically, the harder it is to
successfully cardiovert. Finally, you would not want to cardiovert atrial
fibrillation in a patient with three days of symptoms without either a
transesophageal echo to exclude a clot or without having given three
weeks of anticoagulation prior to the cardioversion.
Topic:
Cardiology
Record # 25
Question/Fact:
(C) Send blood for cortisol and treat with hydrocortisone and
normal saline
Explanation:
Record # 26
Question/Fact:
Although the patient is on procainamide and isoniazid, which can both give
a positive ANA and lupus, her clinical presentation is not consistent with
drug-induced lupus. She has very clear renal involvement with proteinuria
and red cell casts in the urine, as well as an elevated BUN and creatinine.
She also experienced some episodes of confusion, which might be lupus
cerebritis. Neither central nervous system nor renal involvement is found
with drug-induced lupus. She also has hematological disease, which is rare
with drug-induced lupus. The best way to confirm the diagnosis is with a
renal biopsy. Antihistone antibodies, LE cells, and single-stranded DNA
antibodies can be found in both spontaneous lupus and drug-induced
lupus. In addition, the renal biopsy will greatly help in the choice of therapy
because it tells us who needs cyclophosphamide or azathioprine in
addition to steroids for the management of diffuse proliferative renal
disease. Antimitochondrial antibodies are seen with primary biliary
cirrhosis, not lupus.
Topic:
Rheumatology
Record # 27
Question/Fact:
Record # 28
Question/Fact:
Record # 29
Question/Fact:
This patient has congestive heart failure (CHF) due to diastolic dysfunction
secondary to chronic hypertension, with no mention of left ventricular (LV)
systolic dysfunction. Diastolic dysfunction is more common in elderly,
hypertensive patients. Signs of pulmonary or venous congestion in
patients with a LV chamber of normal size indicate diastolic dysfunction.
The hypertrophic, stiff left ventricle needs more time to fill during diastole,
so treatment with beta-blockers helps in slowing the heart rate and
increasing cardiac output. Even though he has asthma, his is not wheezing
now, and so it would be best to decrease his mortality with beta-blockers.
Diuretics and nitrates should be used with caution because the decrease in
preload may decrease cardiac output and cause hypotension. The use of
increased diuretics is helpful in volume-overloaded patients for relief of
severe edema, which is not present in this case. Reassurance, dietary
modification alone, and rescheduling a return appointment is not an option
in this symptomatic patient. ACE inhibitors are more helpful in patients
with LV systolic dysfunction and for lowering the systolic blood pressure.
This patient already has prerenal azotemia, and so it would be best to not
simply deplete the intravascular volume even further with more diuretics.
Positive inotropic agents like digoxin are effective in patients with CHF
secondary to systolic dysfunction. Although they do not reduce mortality,
these agents are effective in reducing rates of hospitalization and in
improving symptoms. They are also useful when worsening heart failure is
from atrial fibrillation with poor rate control.
Topic:
Cardiology
Record # 30
Question/Fact:
histology on biopsy
(C) The risk of developing esophageal cancer is approximately
0.5% per year
(D) There is clear evidence that an endoscopy every year for
surveillance will decrease morbidity and mortality
(E) A proton-pump inhibitor daily should be prescribed
Answer:
Record # 31
Question/Fact:
(A) Echocardiogram
(B) Diltiazem
(C) Electrical cardioversion
(D) Heparin 5,000 U bolus, then start heparin drip
(E) ASA 325 mg daily
(F) Coumadin
Answer:
The patient presents with atrial fibrillation leading to a stroke. The most
urgent step is to start anticoagulation to prevent a recurrent episode. An
echocardiogram certainly does need to be done, but given the history of
the atrial arrhythmia and stroke, the patient will need anticoagulation no
matter what it shows. The rate is <100/min, so diltiazem will not help. This
patient is hemodynamically stable, so electrical cardioversion is not
necessary. In fact, cardioversion without anticoagulation is contraindicated
because it might allow another embolus to develop. If the patient did not
have the atrial arrhythmia, then aspirin alone would be useful. Coumadin
should be started in addition to the heparin. As a single agent, the effect of
coumadin would not be rapid enough.
Topic:
Cardiology
Record # 32
Question/Fact:
Record # 33
Question/Fact:
A 41-year-old woman comes to clinic with hair loss for the past
month and energetically asks you to refer her to a "hair
specialist." She denies cough, fever, or weight change but
mentions that she has constantly felt tired and has had difficulty
concentrating lately. She also has frequent headaches and
muscle cramps. Her menstrual cycle is usually regular, but now
she has been having amenorrhea for the past two months. She
is HIV positive, her CD4 count is 78/ L, and the viral load is
undetectable. She also has a history of atrial fibrillation, which
has required defibrillation several times. Sotalol, procainamide,
and quinidine have been ineffective in maintaining her sinus
Record # 34
Question/Fact:
(B) Electrocardiogram
Explanation:
Record # 35
Question/Fact:
and insulin may be used, but this needs to be done only in a carefully
monitored setting.
The usual treatment is to give potassium orally for the acute episode every
15 to 30 minutes with careful monitoring of the EKG, the potassium level,
and muscle strength. Intravenous potassium is reserved for patients such
as this who have profoundly severe muscular weakness. When giving
intravenous potassium, it should be mixed with mannitol rather than
dextrose because the insulin that is generated by the dextrose will cause
more intracellular shift of potassium and can worsen the paralysis.
Acetazolamide, a carbonic anhydrase inhibitor, has been used to prevent
attacks presumably by causing a metabolic acidosis. It may paradoxically
cause a drop in the potassium level, and potassium supplements may need
to be given as well. Beta-blockers may also decrease the frequency of
attacks. Avoidance of high-carbohydrate meals and eating a low-salt diet
should also be helpful. In this patient, overcoming the acute attack is the
most important step, and the best treatment for this patient is to give
potassium intravenously because he is so profoundly weak.
Topic:
Nephrology
Record # 36
Question/Fact:
(A) Furosemide
(B) Amiodarone
(C) Beta-blocker
(D) Digoxin
(E) Spironolactone
Answer:
(C) Beta-blocker
Explanation:
The patient has congestive heart failure. Because this patient is young (25
years of age), ischemia is extremely unlikely as the etiology. Although a
murmur of mitral regurgitation is present in this patient and valvular
disease is certainly a cause of congestive failure, the valve disease in this
patient is more likely the result, not the cause, of the congestive failure.
This patient seems to have a dilated cardiomyopathy without a clearly
identified etiology. There is no history of alcohol abuse, Chagas' disease,
use of Adriamycin, or radiation exposure to explain the disease.
Connective tissue disorders such as lupus, polyarteritis nodosa, and
rheumatoid arthritis also cause dilated cardiomyopathy, but it is extremely
difficult to attach the cause to these diseases without any other systemic
manifestations. Idiopathic dilated cardiomyopathy is most often related to
previous viral myocarditis that may not have been specifically diagnosed at
the time of the initial infection.
All of the drugs listed in the answers are useful in this patient, but the betablockers will result in the greatest decease in mortality. Digoxin and
diuretics have no direct evidence of decreasing mortality. Amiodarone is
the best antiarrhythmic for a patient with atrial fibrillation, dilated
cardiomyopathy, and diminished left ventricular function, but there is
inconclusive evidence of an effect upon mortality. Although ACE inhibitors
will lower mortality, beta-blockers will lower it even more. The greatest
effect on mortality with beta-blockers is in patients with the worst
ventricular function. This patient's profoundly low ejection fraction under
25% actually indicates an even greater benefit from the beta-blockers, with
a nearly 40% reduction rate in mortality.
Topic:
Cardiology
Record # 37
Question/Fact:
The patient most likely has developed a ventricular aneurysm. His history
of a myocardial infarction several weeks to months ago combined with the
absence of symptoms are consistent with this disorder. He has no
symptoms today, making a new infarction unlikely. Dressler's syndrome
would either give pleuritic chest pain altering with body position and
respiration and a rub, or it would give diffuse ST-segment elevation in
virtually all the leads. Right heart failure would give hypotension, dyspnea,
and the jugular venous distension and peripheral edema consistent with
the backflow of blood into the venous system. Also, right heart failure
Record # 38
Question/Fact:
Lifestyle modification for this patient would be eating three meals per day
(as opposed to one large meal), the discontinuance of tobacco use, and
avoidance of weight gain. These are the most important aspects of
treatment of mild gastroesophageal reflux disease.
Topic:
Gastroenterology
Record # 39
Question/Fact:
Hematology-Oncology
Record # 40
Question/Fact:
months, would be too dangerous for the patient. He does not have a wellcontrolled virus. Changing his regimen to two new nucleoside reversetranscriptase inhibitors and a new protease inhibitor is not suggested
without knowledge of the viral genotype. There is a possibility that the
virus would be resistant to new medications as well. Besides this,
changing from nelfinavir to ritonavir is not suggested in light of the lipid
abnormalities already present. The abnormalities would likely only worsen
on ritonavir.
Topic:
Infectious Diseases
Record # 41
Question/Fact:
Record # 42
Question/Fact:
Record # 43
Question/Fact:
over thirty years. He has lost about 20 pounds over the last
month.
Physical examination reveals: temperature 98.7 F, blood
pressure 140/80 mm Hg, heart rate 88/min, and respiratory rate
16/min. Lungs are clear to auscultation. On neurologic exam, the
cranial nerves are intact. Muscle strength in the extraocular
muscles is intact. Muscular strength in the extremities is
decreased to 4/5, and the weakness is more pronounced in the
proximal muscle groups. His strength increases after several
minutes of repetitive exercise.
A chest x-ray reveals a 2-cm lesion in the left upper lobe with
hilar and mediastinal lymph-node enlargement. The initial
complete blood count and chemistry panel are unremarkable.
Tensilon (edrophonium) test is of questionable effect. An EMG is
ordered, and the anti-acetylcholine receptor antibody level is
pending.
What will be the most effective treatment of this patient's
neurologic condition?
(A) Pyridostigmine
(B) Thymectomy
(C) Prednisone
(D) Plasmapheresis
(E) Chemotherapy and radiation
Answer:
Record # 44
Question/Fact:
(A) Angioplasty
Explanation:
Record # 45
Question/Fact:
screening should begin at age 40 or ten years prior to the age of the family
member. The earlier date is respected. Follow-up examinations for persons
with family histories of colon cancer should occur at 5-year intervals. When
there are multiple family members, screening colonoscopy should be
performed at age 25 and every 1 to 2 years (characteristic of persons with
hereditary nonpolyposis colorectal cancer (Lynch syndrome). Colonoscopy
is recommended 1 year after a hemicolectomy for colon cancer to verify the
absence of recurrence and the presence of new lesions.
Topic:
Gastroenterology
Record # 46
Question/Fact:
Record # 47
Question/Fact:
(C) Metoprolol
Explanation:
Record # 48
Question/Fact:
(D) She should take folic acid 4 mg daily prior to conception and
in the first several months of pregnancy
Explanation:
This patient has a child with a neural tube defect, and she is at increased
risk of having another child with a similar abnormality compared with the
general population. Her risk can be reduced by taking folic acid in high
doses at 4 mg a day prior to the conception and in the beginning of
pregnancy. There is evidence that periconceptual folic-acid supplements
can decrease the risk of neural-tube defects in the fetus. The U.S. Public
Health Service recommends supplementing all women with 0.4 milligrams a
day of folic acid, even without a prior history of having a child with a
neural-tube defect. This is also recommended for women with epilepsy. You
should not stop the seizure medications because having a seizure during
the pregnancy will be harmful to both the fetus and the mother.
Topic:
Neurology
Record # 49
Question/Fact:
A 48-year-old man with AIDS comes to clinic for a regular followup. He was recently started on zidovudine (AZT or ZDV),
lamivudine, and nelfinavir. He was previously seen by a different
doctor in the clinic. The patient states that his viral load is now
undetectable. His white count is 1,200/mm 3 with 75%
neutrophils. Six months ago, his viral load was 65,000, and his
white cell count was 7,500/mm3 with 65% neutrophils. What is
the most appropriate action at this time?
(A) Switch lamivudine to didanosine
(B) Switch nelfinavir to efavirenz
(C) Start colony-stimulating factor
(D) Bone-marrow biopsy
(E) Switch the zidovudine (AZT) to stavudine
Answer:
The patient has done well with this new regimen in terms of the viral load;
Record # 50
Question/Fact:
treatment. If cultures remain positive after three months, the isolate should
be retested for susceptibility, and possible changes should be made in the
drug regimen. If the organism is fully susceptible to all the medications the
patient is on, then you should suspect noncompliance with medications.
Directly observed therapy should be used for these patients. Response to
treatment can also be monitored by acid-fast bacilli (AFB) smear
examination. This is not as accurate as sputum cultures because even
patients who are being effectively treated can still shed nonviable (i.e.,
dead) AFB for several months after the start of effective therapy. Monitoring
by smear is only done when culture monitoring is not possible. Positive
smears after five months are indicative of treatment failure.
Serial chest x-rays are not recommended for monitoring responses for
follow-up because x-ray changes lag behind, and they are not a sensitive
method of detecting treatment failure. You don't want to wait for patients to
get sicker in order to tell who has failed therapy. Cultures and smears can
detect treatment failure with far greater sensitivity than clinical
deterioration. Although blood testing for aminotransferases is
recommended at baseline for all patients, these tests do not have to be
done routinely during therapy. Repeated testing for elevated transaminases
should be performed if there is clinical evidence of illness, the patient is
pregnant or an alcoholic, or if the baseline tests are elevated.
Topic:
Pulmonary
Record # 51
Question/Fact:
Record # 52
Question/Fact:
(C) Colonoscopy
Explanation:
This patient has an anemia of chronic disease from renal failure as well as
iron deficiency. There is a deficiency of erythropoietin secretion because of
renal failure, which usually causes a normocytic anemia with a decreased
reticulocyte count. The other cell lines should be unaffected. Despite being
on erythropoietin for two months, he is not symptomatically better, and his
laboratory tests suggest an iron deficiency. His cells are microcytic, the
ferritin is low, and the total iron-binding capacity (TIBC) is elevated. If this
were just anemia form renal insufficiency, he would have a high ferritin
level and a low TIBC. Increasing the erythropoietin alone will have no effect
on the blood count.
The most common cause of iron deficiency is blood loss. In a man above
the age of 50, gastrointestinal blood loss is certainly the most common
cause. Beside the anemia, being older than 50 requires that he get a
colonoscopy once every ten years to screen for colon cancer. He is
hemodynamically stable with no orthostatic changes, no chest pain, and no
EKG changes, and the hematocrit is above 30%; therefore, transfusion at
this time is not indicated. Although we would be treating his iron deficiency
with ferrous sulfate, the more important underlying cause would be
ignored. Although a bone marrow biopsy is the most sensitive method of
detecting an iron-deficiency anemia, it is not necessary in this case.
Topic:
Hematology-Oncology
Record # 53
Question/Fact:
(B) Bicarbonate
Explanation:
Record # 54
Question/Fact:
Explanation:
Record # 55
Question/Fact:
This patient presents with what is most likely chlamydial salpingitis and
cervicitis. Mucopurulent cervicitis in 50% of patients is caused by C.
trachomatis. The patient may complain of mucoid vaginal discharge.
Unless concurrent bacterial vaginosis is present, the vaginal discharge
lacks an odor. The diagnosis should initially be established clinically
because C. trachomatis is difficult and expensive to culture. Cervical
motion tenderness and a cervical discharge is enough to indicate a need
for antibiotics. A patient with a negative Gram stain and the absence of
Neisseria gonorrhoeae on culture is assumed to have a chlamydial
infection. Direct immunofluorescence assay and the DNA probe test can be
used for screening but are less sensitive than culture or ligase chain
reaction (LCR). The LCR test has superior sensitivity (90-95%). It also has
an excellent specificity, approaching 100%, and it can be performed on
urine. Vaginal ultrasonography will not help to isolate the organism. It
would assist in the assessment of the amount of anatomical damage, such
as with an abscess or an ectopic pregnancy. Laparoscopy is the most
invasive method that can be used to obtain specimens to direct evaluation
and treatment. Laparoscopy is used when a patient has recurrent infection
or when a patient does not respond to therapy, and the most exact of all
methods of testing is necessary.
Topic:
Infectious Diseases
Record # 56
Question/Fact:
The patient has developed pulmonary emboli from the proximal venous
thrombi in the leg as suggested by tachypnea, tachycardia, and a wide A-a
gradient on the blood gas. There is clear evidence of a source of the emboli
on venous Doppler studies of the lower extremities. The next best step in
the management of this patient is to prevent further embolization, therefore
justifying the emergent placement of an intracaval filter. Although the
diagnosis of pulmonary embolism with spiral CT or V-Q scanning would be
helpful in validating the use of anticoagulation, they would not be useful for
stabilizing the patient at this time. In addition, the weight of evidence for a
pulmonary embolus is so overwhelming in this patient that even if the V/Q
scan were low probability for an embolus, you would still continue to treat
the patient anyway. These tests will not change your acute management.
Coumadin, although indicated, would not be effective in the immediate
treatment of this patient. Although the patient is tachypneic, there does not
appear to be any signs of acute respiratory failure. For this reason, acute
intubation and mechanical ventilation are not warranted at this time. The
filter is the most urgent step here because of the high likelihood of
Record # 57
Question/Fact:
A 76-year-old man who was a smoker for the past 30 years with
a history of chronic obstructive pulmonary disease (COPD)
presents to the emergency department with a low-grade fever
and increasing cough for the past three days. He also complains
of shortness of breath for the past 48 hours. He worked as a
nurse for 30 years and had a chronic hepatitis B infection for
which he received interferon-2-alpha for 16 weeks and tolerated
it well. During the physical examination, he has a large loose
stool and appears acutely ill and confused. His temperature is
101 F, respirations are 24/min, pulse is 100/min, and blood
pressure is 130/80 mm Hg. He has diffuse coarse expiratory
rhonchi in both lungs. Laboratory studies show: hematocrit
33%, white cell count 16,000/mm3, platelets 150,000/mm3, sodium
128 mEq/L, bicarbonate 24 mEq/L, BUN 24 mg/dL, creatinine 1.2
mg/dL, and glucose 140 mg/dL. The chest x-ray shows hazy
interstitial infiltrates. Sputum Gram stain shows only white cells.
What should be the next step in the management of this patient?
(A) Transtracheal aspirates for Gram stain and culture
(B) Oral antibiotics
(C) Admit to hospital and start intravenous azithromycin and
ceftriaxone
(D) Do blood cultures and start on intravenous cefuroxime
(E) Bronchoscopy
Answer:
In this case, an age above 70 (70 points), the presence of liver disease (20),
mental status changes (20), and sodium level below 130 (20) gives a total of
130 points. This patient should definitely be hospitalized.
Topic:
Pulmonary
Record # 58
Question/Fact:
pain, severe fatigue, and myalgias. Her dentist had treated her
twice for "tooth infections" over the last two months. She
remembers taking amoxicillin and clindamycin, respectively.
Her physical examination today shows a temperature of 103 F, a
pulse of 110/min, and a respiratory rate of 26/min. Her oxygen
saturation is 96% on room air. She has left facial swelling and
decreased breath sounds bilaterally. She has heme-positive,
brown stool and slightly diminished strength in all extremities.
She has edema of the lower extremities. Laboratory studies
show the following findings:
WBC: 22,000/mm3; hematocrit: 33%, platelets:
300,000/mm3; Na 136 mEq/L; K: 3.0 mEq/L; BUN: 62 mg/dL;
creatinine: 3.8 mg/dL; C-ANCA: 1:160; P-ANCA negative;
and ANA negative. Urinalysis shows: hemoglobin 3+,
protein 2+, and erythrocyte casts. The chest x-ray shows a
left lower lobe infiltrate.
Which of the following is the most accurate statement?
(A) Emergency dialysis is needed.
(B) Cyclophosphamide and glucocorticoids result in markedly
improved patient survival and renal function survival.
(C) Cyclophosphamide and glucocorticoids result in markedly
improved overall survival but does not alter course of renal
disease.
(D) TMP/SMX should be started prior to other modalities.
(E) Glucocorticoid in pulse doses should be started as initial
sole therapy.
Answer:
Record # 59
Question/Fact:
(A) Echocardiogram
Explanation:
Record # 60
Question/Fact:
(C) Hemodialysis
Explanation:
This patient has features of acute interstitial nephritis most likely caused
from the recently started phenytoin. Drugs account for 70% of acute
interstitial nephritis. The most common drugs are penicillin, rifampin,
cephalosporins, sulfonamides, nonsteroidal anti-inflammatory drugs
(NSAIDs), phenytoin, and allopurinol. These are the medications, in
general, that people are allergic to. The process that goes on in the
kidney is a reflection of the generalized rash and eosinophilia that can
occur from the same drugs in general.
Other causes are streptococcal infections, cytomegalovirus,
Record # 61
Question/Fact:
Record # 62
Question/Fact:
Answer:
Record # 63
Question/Fact:
(B) Hydroxychloroquine
Explanation:
This patient presents with psoriatic arthritis, which improved with NSAIDs
for a period of about 6 months. She came back with worsening joint pain
and scaly lesions of the scalp. This is the time when disease-modifying
medications have to be started. The patient was most likely started on
hydroxychloroquine. Although hydroxychloroquine is often successful in
producing either amelioration or remission of the disease, it carries a
significant risk of the exacerbation of psoriasis and subsequent worsening
exfoliation. Sulfasalazine has very good efficacy in psoriatic arthritis. For
more severe cases of psoriatic arthritis with exfoliation and arthritis, 5 to 25
mg of methotrexate per week is recommended, along with folic acid to
prevent hematological complications. Steroids are not used and are not
categorized as disease-modifying drugs in psoriatic arthritis. Intramuscular
gold can be used weekly as a disease-modifying drug. None of the other
drugs are known to cause worsening of exfoliation, besides the
antimalarial medications.
Topic:
Rheumatology
Record # 64
Question/Fact:
Record # 65
Question/Fact:
This patient with a history of congestive heart failure (CHF) has signs of
fluid overload, manifested by increased shortness of breath and weight
gain. Evidence strongly suggests that beta-blockers prolong the survival of
such patients, who then should be instructed to monitor their weight at
home and to report any increase or change in symptoms immediately. The
administration of a diuretic will often relieve volume overload and allow
patients to continue beta-blockers. Carvedilol, because of its alphablocking activity, may cause dizziness or hypotension. The benefits from
beta-blockers may not be evident immediately and can take 2 to 4 months
to become evident. Although digoxin is useful in symptomatic patients,
particularly those not controlled with ACE inhibitors, this patient's main
problem seems directly related to fluid retention and weight gain; it is not a
problem with worsening contractility. It is premature to refer for
transplantation until you have used the maximal medical therapy from all
classes. Besides that, you would need to start the diuretic anyway while
you wait for the availability of a matched organ.
Topic:
Cardiology
Record # 66
Question/Fact:
(B) Leukapheresis
Explanation:
One may notice that there was no differential given for the markedly
elevated white blood cell count. That is because it would not alter the next
step in therapy, which is leukapheresis. The patient has a markedly
elevated white cell count and severe signs of sludging in the vasculature,
such as lethargy, confusion, blurred vision, dyspnea, and priapism. The
most rapid way to lower the cell count is with leukapheresis. Hydroxyurea
is very good at lowering the cell count and can be used orally but will still
need days to work. Busulfan is an antiquated drug that was used in the
past to do the same thing. Busulfan is less effective than hydroxyurea and
causes permanent pulmonary fibrosis. (When you see busulfan in a
therapy question, it is always a wrong answer.) Although an allogeneic
transplant may eventually be needed for AML, CML, or ALL, you would
never do this first. Transplants are performed after chemotherapy is used
to induce a remission. Daunorubicin and cytosine arabinoside (cytarabine)
are used as initial therapy in AML. The same reasoning is true as that
described for CML. The patient may need these drugs later, but they do not
act as rapidly as leukapheresis.
Topic:
Hematology-Oncology
Record # 67
Question/Fact:
This patient has mesial temporal lobe epilepsy syndrome (MTLE), which is
associated with complex partial seizures. Distinctive clinical,
electroencephalographic, and pathological features define this syndrome.
There is usually a history of febrile seizures and a family history of
seizures. The seizures may remit and reappear. Auras are common. Such
patients usually have unilateral posturing, complex automatisms,
behavioral arrest/stare, and postictal disorientation, memory loss, and
dysphasia with a dominant hemisphere focus. Laboratory studies show
unilateral or bilateral anterior temporal spikes on EEG. There are also
material-specific memory deficits on the amobarbital (Wada) test. MRI
Record # 68
Question/Fact:
the head and neck does not show any abnormalities. Oral
nimodipine is started. What is the next step?
(A) Start e-aminocaproic acid
(B) Repeat MRA in one week
(C) Volume expansion therapy
(D) Start mannitol
(E) Four-vessel cerebral angiogram
Answer:
Record # 69
Question/Fact:
This patient has primary syphilis. She has a genital ulcer, a positive RPR at
a high titer, and a positive FTA. Even though this is syphilis, the chancres
can sometimes be tender. Pregnant patients should receive penicillin
following the dosage schedule appropriate for the stage of syphilis in the
same manner as recommended for nonpregnant patients. If the patient has
a well-documented penicillin allergy, as this patient does, the
recommendation is for penicillin desensitization until a full dose is
tolerated. Doxycycline should not be used in a pregnant patient for any
disease because of possible harm to the fetus. Erythromycin should not be
used because it is not proven to effectively cure the fetus. You cannot hold
therapy until delivery because the baby will have a much higher likelihood
of developing permanent neurological deficits. You can't just give an
antihistamine before penicillin in a patient with a severe allergy. The
antihistamine gives insufficient efficacy in preventing serious allergic
reactions. Ceftriaxone has not been proven to be effective in congenital
syphilis.
Topic:
Infectious Diseases
Record # 70
Question/Fact:
Record # 71
Question/Fact:
Record # 72
Question/Fact:
Record # 73
Question/Fact:
Record # 74
Question/Fact:
This patient presents with a dendritic ulcer, which is almost always caused
by a herpes infection. Sometimes they can be caused by corneal abrasions
or excessive use of contact lenses. If this were simply a reaction to the
contact lens solution, there would not be a dendritic pattern visible on
fluorescein staining. A herpetic, dendritic ulcer usually presents with a
painful eye, visual blurring, and conjunctival inflammation. The treatment is
with ophthalmic trifluridine and acyclovir for about 10 days.
Record # 75
Question/Fact:
Record # 76
Question/Fact:
(B) Allopurinol
Explanation:
Allopurinol is a xanthine-oxidase inhibitor that promptly lowers plasmaurate and urinary uric-acid concentrations. It is of special value in uric acid
overproducers, tophaceous gout, and in patients unresponsive to
uricosuric agents. Allopurinol is also helpful in patients with uric-acid renal
stones. It should be used in low doses in patients with renal insufficiency.
The patient is already on low-dose colchicine on a daily basis. He should
be continued on this medicine because in an older patient with occasional
attacks, this may be all that is needed to prevent recurrences. Colchicine
should be used once a day in moderate renal insufficiency, such as in this
patient's case.
Probenecid is a uricosuric drug that is contraindicated in this patient
because the creatinine level is elevated above 2 mg/dL. Probenecid and
sulfinpyrazone are two uricosuric drugs that may be used with normal
renal function. NSAIDs are used for the treatment of an acute attack and
are relatively contraindicated with impaired renal function, as in this case.
Steroids should be used in the case of an acute attack for those patients
Record # 77
Question/Fact:
The patient has facial palsy because of Lyme disease. Facial palsy is
adequately treated with oral doxycycline. The positive IgM antibody test for
Borrelia burgdorferi has sufficient specificity in this case to indicate the
need for therapy. A repeat test is not necessary. In the absence of other
neurologic abnormalities, a lumbar puncture is not necessary. Intravenous
therapy does not give a greater efficacy when compared with oral
doxycycline.
Topic:
Infectious Diseases
Record # 78
Question/Fact:
(B) Methotrexate
Explanation:
Record # 79
Question/Fact:
(E) Donepezil
(F) Ventriculo-peritoneal shunt
Answer:
Even if you have no clue about the diagnosis, the first step in managing a
patient with severe CNS-related abnormalities is a CT scan of the head in
virtually any question you encounter on the boards. This patient has
normal-pressure hydrocephalus (NPH). The gait disorder is usually
characteristic and is the most reliable feature. Typically, the family
describes the subacute onset of progressive intellectual deterioration
accompanied by slowness and restriction of movement, particularly of the
gait. There should also be the presence of bladder incontinence. In a way, it
can be thought of as Parkinson's disease of the lower extremities. The
disease is slowly progressive over weeks, months, or sometimes years.
Parkinson's disease has many clinical features that are not present in NPH,
such bradykinesia, rigidity, rest tremor, freezing, and postural instability. All
of these are absent in this patient. In addition, NPH will not have a
response to Sinemet. Although metoclopramide can cause a secondary
parkinsonism, it should not cause cognitive decay or urinary incontinence.
And even though donepezil may be useful for Alzheimer's disease, it will
not help the memory loss of NPH. Ventriculo-peritoneal shunting would not
be appropriate, unless a CT scan of the head is performed first. In short,
don't start disease-specific therapies until you have confirmed a specific
disease. Lumbar puncture is not a useful prognostic test. The only proof of
shunt efficacy is to perform the shunt. Success is more likely if the shunt is
done before the onset of severe cognitive problems.
Topic:
Neurology
Record # 80
Question/Fact:
His EKG is normal. In order to clear him for exercise, you order a
thallium stress test, which shows a small reversible defect in his
inferior wall. How would you manage him?
(A) Clear him for racquetball
(B) Tell him he will have no problem as long as he loses 10% of
body weight prior to beginning exercise
(C) Start aspirin alone
(D) Start statins
Answer:
Although he has no cardiac risk factors, he has an LDL above 130 and a
sestress test showing ischemia. Once you have the presence of coronary
disease, risk factors such as hypertension, tobacco smoking, low HDL,
family history, and the patient's age become irrelevant. Although obesity is
certainly a risk for an increase in all-cause mortality, obesity is not
specifically a risk factor in the evaluation of who needs lipid-lowering
therapy. Statin therapy would be combined with a dietary restriction on fat
intake, as well as weight loss.
Topic:
Cardiology