An 80-year-old woman comes to the urgent care clinic with dyspnoea on exertion. On physical examination, her blood pressure is 100/70, and her pulse is 75. She has no pulsus paradoxus. Her jugular veins are distended, and she has distant heart sounds. In addition, she has extra third and fourth heart sounds. Her liver is enlarged, and she has pedal oedema. She has occasional premature ventricular contractions on her electrocardiogram. A chest x-ray reveals clear lung fields with a dilated cardiac silhouette. Her echocardiogram reveals ventricular walls with a “speckled pattern”. Which of the following is the most likely diagnosis?
- Alcoholic cardiomyopathy
- Amyloidosis
- Haemochromatosis
- Tuberculosis
- Viral myocarditis
Amyloidosis
Restrictive cardiomyopathy with ‘speckled’ left ventricular wall
Primary cardiac amyloidosis usually develops into diastolic dysfunction
Alcoholic cardiomyopathy: biventricular dilated cardiomyopathy
A 92-year-old man with a 45-year history of chronic obstructive pulmonary disease is intubated in the ICU because of a bout of viral pneumonia that fails to improve after 72 hours of antibiotics. Although the inspired fraction of oxygen is 100%, the patient’s pO2 remains at 57 mmHg. Positive-end expiratory pressure (PEEP) is added to allow the inspired fraction of oxygen. Twelve hours after the introduction of PEEP the patient suddenly become hypotensive. At the same time, his oxygen saturation drops from 92% to 61%. On physical examination, his BP is 80/50 mmHg and his pulse is 124/min. He has distended neck veins and distant heart sounds. Which of the following would also most likely be seen on this patient’s physical examination?
- Absence of breath sounds in the right hemithorax
- High amplitude carotid artery upstroke
- A pleural friction rub
- Pulsus alternans
- Splenomegaly
Absence of breath sounds in the right hemithorax
Patient has developed a tension pneumothorax, characterised by PEEP followed by sudden hypotension and decreased oxygenation
Jugular venous distention occurs because venous return to the right side of the heart is being compressed
Rx: immediate needle/tube thoracostomy
A 46-year-old man with a history of hypertension and hypercholesterolemia visits the physician for a routine followup. The patient’s job involves a lot of travelling, and he admits to occasionally forgetting to take his medications with him when he travels. He complains of several episodes of chest pain in the past few months. The pain is sharp in nature, mainly over his lower chest and epigastrium, and tends to come on when walking. He believes these episodes are due to indigestion and has been taking antacids. There is a family history of heart disease, and his father died of a heart attack at age 48. On physical examination, his blood pressure is 150/80 mmHg and heart rate is 86/min. His lungs are clear to auscultation. Cardiac auscultation reveals normal rate and rhythm, without rubs, gallops, or murmurs. There is no pedal oedema. He is sent for an exercise stress test. Five minutes into the test, he develops ST depression of 3mm in leads V1-V5. The ST segment depression is greater than 0.12 seconds in duration and the stress test is stopped. Which of the following is the most appropriate next step in management?
- Coronary angiography
- Holter monitor
- No further tests are required
- Repeat stress test with thallium
- Upper gastrointestinal endoscopy
Coronary angiography
Multiple risk factors for atherosclerotic coronary artery disease
A stress test is considered positive when there are ST depression of >1mm for longer than 0.08 seconds
Positive stress test = coronary angiography
A 74-year-old woman, who has been followed for the past 25 years for chronic obstructive pulmonary disease comes to the ED complaining of 48 hours of temperature to 38.6 C and worsening shortness of breath. She has a chronic productive cough, which has become more copious. On physical examination, she has rhonchi and increased fremitus in the posterior mid-lung field. A Gram’s stain reveals many epithelial cells and multiple gram-positive and gram-negative organisms; no neutrophils are seen. Which of the following is the most likely organism causing the symptoms?
- Escherichia coli
- Haemophilus influenzae
- Klebsiella pneumoniae
- Mycobacterium tuberculosis
- Mycoplasma pneumoniae
Haemophilus influenzae
Evidence of community-acquired pneumonia and common organisms in patients with COPD are Strep. pneumoniae, Haem. influenzae and Moraxella catarrhalis.
Klebseilla pneumonia is typically found in alcoholic patients.
Primary E. coli pneumonia is rare and there is no history of infection elsewhere (e.g. UTI).
Mycoplasma pneumoniae does not present with a lobar consolidation and generally occurs in younger patients – x-ray reveals faint bilateral interstitial infiltrates.
A 62-year-old man is being treated for an acute myocardial infarction. He originally came to the ED with substernal chest pain and diaphoresis. Given his risk factors of hypertension, diabetes, tobacco use, and family history, he is considered high risk. An ECG in the ED reveals a left-bundle branch pattern, and cardiac enzymes are elevated slightly. After a focused evaluation in the ED, the patient receives IV thrombolytics. Although his bundle branch pattern never resolves, the patient is chest pain-free and haemodynamically stable after thrombolysis. Two days later, however, the patient reports episodes of recurrent chest discomfort and shortness of breath overnight. In evaluating for potential myocardial reinfarction, which of the following is the most appropriate diagnostic test?
- Creatinine kinase
- Dynamic ECG changes
- Lactate dehydrogenase
- Myoglobin levels
- Troponin I level
Creatinine kinase
CK, total levels and specific MB fraction, are elevated as early as 3 hours after onset of chest pain and have a duration of no more than 2 days, peaking within 18-24 hours
Myoglobin is the first enzyme elevated and lasts no more than 1 day, but is nonspecific to AMI
Troponin levels increase in 3-12 hours, peak in approximately 1 day, and gradually taper over the next 10 days
A 41-year-old man comes to the clinic complaining of a chronic cough over the past 4 months, which has now been accompanied by haemoptysis. He denies smoking or any past medical history. On physical examination, his head and neck examination is normal. His lungs have diffuse bilateral rales. Cardiac examination is normal. Laboratory findings reveal Na 142 mEq/L, K 4.2 mEq/L, Cl 110 mEq/L, HCO3 24 mEq/L, BUN (blood urea nitrogen) 39 mg/dL, creatinine 2.9 mg/dL. Urinalysis reveals microscopic haematuria and 4+ proteinuria. Which of the following serologic blood tests would most help confirm the suspected diagnosis?
- Anti-glomerular basement membrane antibodies
- Anti-mitochondrial antibodies
- Anti-neutrophilic antibodies
- Anti-parietal cell antibodies
- Anti-smooth muscle antibodies
Anti-glomerular basement membrane antibodies
Haematuria + haemoptysis raises possibility of Goodpasture syndrome
Anti-mitochondrial = primary biliary cirrhosis
Anti-neutrophilic cytoplasmic = Wegener granulomatosisn (similar but + URTI sx)
Anti-parietal cell: pernicious anaemia
Anti-smooth muscle: autoimmune hepatitis
The parents of a 9-year-old girl bring their daughter to the ED. For the last 12 hours, the child has suffered severe nausea and vomiting, as well as diarrhoea and abdominal cramps. Further discussion with the child indicates that she suffers from blurred vision and headache. The parents originally were worried about bringing the child to the ED because they feared deportation since the family are illegal immigrants employed to pick strawberries on a nearby farm. On direct questionning, the parents admit that the child was assisting with spraying crops with pesticides the previous day. None of the family members was wearing any protecting clothing. Her BP is 88/48 mmHg, pulse is 90/min, RR 33/min, Temp 38 C. The child appears sweaty and confused. Auscultation of the lungs reveals a diffuse wheeze bilaterally. Pupils are miotic and the child has diffuse muscle weakness. Which of the following interventions is the most appropriate treatment?
- Atropine
- Charcoal
- Glucagon
- Naloxone
- Pralidoxime
Pralidoxime
Pesticide exposure: consider organophosphate poisoning, which inhibits cholinesterase and results in accumulation of ACh in both muscarinic and nicotinic sites. Pralidoxime activates ACh
Atropine competes with ACh only at muscarinic receptors, but will not reverse nicotinic effects
Charcoal = gastric decontamination
Glucagon = reverse beta-blocker overdose
Naloxone = reverse effects of opioids
A 5-year-old boy suddenly begins coughing while eating peanuts. He is choking and gagging. When he is brought to the ED, but he is awake and is able to give his name. On physical examination, his vital signs are stable. On examination of the chest, inspiratory stridor and intercostal and suprasternal retractions are apparent. Which of the following is the most appropriate initial step in management?
- Allow patient to clear foreign object by spontaneous coughing
- Clear oropharynx with multiple blind sweeps with finger
- Position patient and perform back blows
- Stand behind patient and perform abdominal thrusts
- Perform emergency tracheostomy and take to surgery
Allow patient to clear foreign object by spontaneous coughing
If patient can cough and breathe it is best to initially observe and allow spontaneous resolution, since intervention may actually be damaging
A 35-year-old woman arrives on the floor after an uneventful hysteroscopy to evaluate her long history of uterine fibroids. About 30 minutes after her arrival, she begins to complain of nausea and has two episodes of vomiting. The physical administers 0.625 mg of droperidol and 400 mg of acetaminophen by mouth. On follow-up evaluation, the patient’s neck is involuntarily flexed to one side. She is alert, oriented, and conversation and has an otherwise normal neurological examination. Which of the following is the most likely diagnosis?
- Cerebral vascular accident
- Conversion disorder
- Dystonic reaction to droperidol
- Munchausen syndrome
- Seizure
Dystonic reaction to droperidol
Droperidol antagnosies dopaminergic receptors in the vomiting centre, which can produce torticollic or other dystonias
Munchausen syndrome: mental disorder in which a person fakes illness to gain attention and sympathy
Conversion disorder: neurological sx without a definable organic cause
A 35-year-old woman comes to the ED complaining of chest pressure. She has had such episodes intermittently over the last 5 years, usually when sleeping, but over the last year she has had more frequent severe symptoms that are occasionally associated with severe migraine headaches. The pain is midsternal and is described as pressure that extends as a band around her chest. The ED physician is initially dubious that the pain is cardiac in origin, because the woman has no coronary disease risk factors. An ECG, however, shows 2mm ST-segment elevation and inverted T waves in leads V1 through V5 and 1mm ST-segment depression in leads II, III, and aVF. Before the cardiologist arrives in the ED, the patient’s ECG has returned to normal. This repeat normal ECG is obtained after the administration of aspirin, nitroglycerin, morphine, and oxygen. Which of the following is most likely for these findings?
- Diffuse intimal thickening with focal areas of atherosclerotic narrowing
- Intermittent thrombus formation and lysis in the left anterior descending artery
- Intermittent thrombus formation and lysis in the right coronary artery
- Plaque rupture and thrombus formation in the left anterior descending artery
- Transiently increased coronary vascular tone in the right coronary artery
Transiently increased coronary vascular tone in the right coronary artery
Classic presentation of variant angina, caused by coronary vasospasm that induces transient ischaemia and ST-segment elevations
Raynaud phenomenon or migraines are common clues to the diagnosis
ST-segment elevation that responds to nitroglycerin makes the diagnosis almost certain
A 73-year-old man comes to the ED complaining of abdominal pain. He describes a dull, aching, constant pain in his mid-umbilical region. The pain has persisted over the past few days with increasing intensity, and it is not relieved by changes in position or eating. The patient has a past medical history significant for hypertension and coronary artery disease. He had a myocardial infarction 3 years ago. The man has moderate peripheral vascular disease with a prior femoral-popliteal bypass graft on the left. On physical examination, his BP is 180/100 mmHg, and his pulse is 86/min. He has a loud S4, a pulsatile, midline abdominal mass and venous stasis changes bilaterally on his lower extremities. Which of the following is the most appropriate diagnostic test at this time?
- Abdominal US
- Lumbosacral spine films
- CT of the spine
- CT of the abdomen
- Spinal MRI
Abdominal ultrasound (most cost-effective)
Suspected abdominal aortic aneurysm
A 42-year-old man comes to the physician for his annual physical examination. He was last seen 2 years ago for a periodic health examination and was in god health. He is on no medications. His past medical history is significant for a cholecystectomy 2 years ago and rheumatic fever at age 15. He has been smoking approximately 10 cigarettes daily for the past 23 years. On physical examination, his BP is 154/56 mmHg, pulse 68/min, RR 14/min. He is afebrile. A head and neck examination is normal. His lungs are clear. He has a regular heart rhythm with a II/VI blowing decrescendo diastolic murmur heard at the aortic area. His abdominal and rectal examinations are normal. Complete blood count, electrolytes, and thyroid function tests are normal. Which of the following is the most appropriate advice for this man regarding future preventive health maintenance?
- Antibiotic prophylaxis before dental work
- Annual chest x-ray film
- Annual ECG
- Annual flexible sigmoidoscopy
- Annual prostate specific antigen testing
Antibiotic prophylaxis before undergoing dental work
Physical examination is consistent with asymptomatic aortic insufficiency as a result of childhood rheumatic fever. Patients with any significant cardiac valvular disease should be instructed to have abx prophylaxis before dental work to reduce the risk of subacute bacterial endocarditis.
Sigmoidoscopy and PSA testing would be recommended when >50 years
A 23-year-old man is admitted to the medical services with a severe asthma attack. He is also nauseous and has vomited twice today. The patient has a long history of severe asthma with multiple hospitalisations and one intubation 3 years ago. Two days prior to admission, he was exposed to dust while moving a file cabinet in his basement. Since that time, he has had progressively worsening shortness of breath. He had tried home albuterol and ipratropium nubulizers, as well as his standard cromolyn therapy, but none of these interventions relieved his symptoms. In the hospital, the man’s peak flow rates are decreased by nearly 50% from baseline. Which of the following agents should most likely be added to the patient’s therapy to alleviate his current symptoms?
- Beclomethasone
- Disodium cromoglycate
- Hydrocortisone
- Prednisolone
- Theophylline
Hydrocortisone (IV steroidal agent) to augment the action of bronchodilators by reducing inflammation surrounding the airways.
Beclomethasone (aerosol) is surface-acting and is used with side effects of systemic steroids needs to be avoided.
Disodium cromoglycate: preventer
Prednisolone (oral)
Theophylline: chronic control
A 16-year-old girl is brought to the ED by ambulance after she was extracted from a burning vehicle that had been in an accident on the local highway. She was the only person in her car, which burst into flames after being rear-ended at high speed. She swayer off the road and collided with the side railing. When the ambulance arrived, she was unconscious in the driver’s seat. On arrival at the emergency center, the patient is in moderate respiratory distress. Her pulse is 120/min, BP 80/40, and RR 30/min. After securing the airway and administering oxygen and IV fluid, the physician evaluates the extent of the sustained burn injury. There is diffuse erythema and oedema of her face and most of her scalp hair is scorched, with some blistering of the underlying skin. Both arms show diffuse erythema, oedema, and areas of extensive blistering. The rest of her body shows no significant burns. Which of the following is the estimated body surface area of the burn?
27%
First-degree burns of the face and superficial second-degree burns of scalp and arms – rule of 9s
Head = 9%
Arms = 9% each
Legs = 18% each
Trunk = 18% for front and 18% for back
A previously healthy 27-year-old man comes to the physician complaining of a cough with sputum production for the past 3 days. The cough has been keeping him up at night and it is affecting his job performance. He has no prior history of respiratory disease. His temperature is 37 C, BP 130/80, pulse 70, and RR 18. Physical examination is unremarkable. Which of the following is the most appropriate next step in management?
- Admit for medical management
- Perform chest x-ray
- Perform sputum culture
- Send home with abx
- Send home with no therapy
Send home with no therapy
Likely dx: acute viral bronchitis
If >1 week, macrolide abx may be given
A female infant was born at 31 weeks gestational age following a spontaneous vaginal delivery. The mother had regular prenatal care with negative serologies. Labour lasted 13 hours, and nitrous oxide was used for pain control. Apgar scores were 6 and 7 at 1 and 5 minutes, respectively, because of por respiratory effort and decreased tone. She is transferred to the neonatal intensive care unit, where vitals are monitored continuously and nasal CPAP is begun. Periodic changes in breathing were noted, with absent respiration of 20s duration with each episode. Apneic episodes are associated with a HR of 95 and PaO2 of 70. HR returns to 140 and PaO2 to 95 between episodes. The patient’s temperature is 36.8 C, RR 60, BP 90/50, and birth weight 1680g. Physical exam and routine laboratory results are otherwise normal. Which of the following is the most appropriate pharmacotherapy for this infant’s apnoea?
- Bicarbonate
- Dextrose
- Epinephrine
- Naloxone
- Theophylline
- Phenobarbitol
Theophylline
Apnoea of prematurity: cessation of air flow/exchange for >20s and often associated with bradycardia and hypoxaemia. Occurs in ~50% of infants born at 30-31 weeks due to immaturity of the infant’s neurologic and respiratory systems. First line pharmacologic agents: methylxanthines (caffeine, theophylline) which stimulate respiratory neurons
Bicarbonate: correct acidosis
Dextrose: correct hypoglycaemia
Epinephrine: neonatal resuscitation when HR>80 despite effective ventilation and chest compressions for >30 seconds
A term male infant is found to be cyanotic shortly after birth and requires endotracheal intubation. On physical examination, his blood pressure is 68/34 (equal in all four extremities), pulse 180, and RR 32. His precordium is dynamic, has a grade III systolic murmur, and a single S2. Chest radiography shows a normal heart size and increased pulmonary vascular markings. An arterial blood gas on an FiO2 of 100% shows pH 7.34; PaCO2 47; PaO2 46. Which of the following diagnosis is most consistent with these findings?
- ASD
- Hypoplastic left heart syndrome
- PDA
- Tetralogy of Fallot
- Total anomalous pulmonary venous return
Total anomalous pulmonary venous return
Characterised by pulmonary veins forming a confluence behind the left atrium and draining into the right atrium = right-to-left shunt through foramen ovale
A 63-year-old man is admitted to the hospital for fever and a productive cough. The patient reports that, over the past few days, he has had a worsening cough that has become productive of greenish-crimson sputum. The patient reports temperature to 39.5 C over the past 24 hours. The patient has had nothing to eat or drink for the past 36 hours. On further questioning, the man describes a prodromal period 7 days prior to the onset of the cough that was remarkable for rhinorrhoea and general malaise. On physical examination, the patient appears acutely ill. His BP is 130/80 and pulse 110 and regular. Examination is remarkable for diminished breath sounds on the right lung-base with “a to e” egophony and whispered pectoiloquy. Which of the following is required for diagnosis of pneumonia?
- Hypoxaemia on pulse oximetry
- Infiltrates present on chest radiograph
- Sputum Gram stain showing gram-positive diplococci
- Sputum Gram stain showing neutrophils
- Temperature to 38.6 C
Infiltrates present on chest radiograph
Hypoxaemia is one possible physical manifestation of severe pneumonia but is not required for diagnosis
Other signs are non-specific for pneumonia
A 27-year-old primigravid woman with type 2 diabetes mellitus comes to the ED in the 34th week of gestation because of a rapidly enlarging “stomach” and the sudden onset of contractions. She has not had much prenatal care since the first trimester because of a complicated family situation and lack of medical insurance. She had been feeling well until several days earlier when she noticed that her ‘stomach’ was rapidly growing and when she started having contractions that morning she decided to go to the hospital. On examination, her abdomen is much distended and the uterus is large by palpation. She is fully dilated and has contraction 2-3 minutes apart. She is admitted to the delivery room and several hours later she delivers a boy who weighs 2500g and is 38cm long. His APGAR scores are 6 and 7. Physical examination of the child reveals a scaphoid abdomen and a palpable fullness of the epigastrium. An abdominal radiograph of the infant shows gaseous distention of the stomach and proximal duodenum. A nasogastric tube is placed and suction produces bilious fluid from the stomach. Which of the following prenatal studies might have revealed this abnormality?
- Alpha fetoprotein level
- Antibody screens for common foetal infections
- Haemoglobin electrophoresis
- Human choriogonadotropin levels
- Ultrasonography
Ultrasonography
Suspect duodenal atresia
Prenatal ultrasonography may reveal a dilated and fluid-filled stomach and duodenum
Scaphoid abdomen: anterior abdominal wall is sunken and presents a concave rather than complex contour
A 9-month-old girl with Down syndrome is brought to the office for followup of a respiratory tract infection. This is the third time in 3 months that she has been treated for pneumonia. She has difficulty feeding and is not gaining weight. She frequently pauses during eating and has to calm down to be able to continue. She also has difficulty breathing when she cries. The parents have noticed that she started crawling over the past week but gets tired easily and seems to have an aversion to activity of any sort. Her medical history is significant for multiple respiratory tract infections, pneumonia, and poor growth. On physical examination, the patient is below the fifth percentile for weight and height. Her lips are mildly cyanotic. She has a hyperinflated thorax and a bulging precordium. Auscultation of the heart reveals that the second heart sound is widely split with no respiratory variations. There is a systolic ejection murmur at the upper left sternal border and a diastolic rumble at the lower left sternal border. Chest radiography demonstrates a grossly enlarged heart with a prominent pulmonary artery and increased pulmonary vascular markings. Which of the following is the most likely diagnosis?
- ASD
- Endocardial cushion defect
- Mitral regurgitation
- Tetralogy of Fallot
- VSD
Endocardial cushion defect: occurs when an ASD and VSD are present and contiguous, and the atrioventricular valves are also abnormal
A 72-year-old man with a 25-year history of emphysema comes to his physician after he develops the acute onset of fevers, rigors, and a cough productive of green sputum. The symptoms gradually worsen over 36 hours and he comes to the ED. He has been taking a beclomethasone inhaler twice daily, an albuterol nebuliser treatment at home four times daily, and has been taking erythromycin for a recent bronchitis. On physical examination he is 183cm tall and weighs 85kg. His temperature is 38.3 C, BP 162/92, pulse 94, and RR 32. His lung examination reveals diffuse bilateral coarse rhonchi. He uses his sternocleidomastoid muscles with each inspiration. An arterial blood gas reveals a pH of 7.2, pCO2 60 and pO2 52. Over the next 2 hours, he becomes increasingly tachypnoeic and his pCO2 rises to 74. The decision is made to intubate him at that point. Which of the following settings would be most appropriate for his tidal volume on the respiratory?
- 500 mL/breath
- 600 mL/breath
- 700 mL/breath
- 850 mL/breath
- 1000 mL/breath
850 mL/breath
The tidal volume for a patient is generally estimated as 10 mL/kg of weight. Giving a lower tidal volume will yield hypoventilation and be insufficient to eliminate pCO2. A tidal volume > 10 mL/kg increases the risk of pneumothorax
A patient with a history of hypertension calls his physician’s office for advice. He has had longstanding heartburn and recently consulted with a gastroenterologist. He underwent an endoscopy and was told that “Barrett’s mucosa” was found by biopsy. The patient has read in the newspaper that people with this condition will probably develop oesophageal cancer. Which of the following is the most appropriate response to this concern?
- “Your concerns are ungrounded”
- “It is foolish to worry because this type of cancer is unlikely to develop and would occur many years later”
- “You should chew food very carefully to prevent the possibility of a mechanical obstruction”
- “Only a small minority of patients with Barrett’s oesophagus will develop cancer, and you should undergo endoscopic surveillance”
- “You should consult with an oncologist regarding oesophageal cancer prevention strategies”
“Only a small minority of patients with Barrett’s oesophagus will develop cancer, and you should undergo endoscopic surveillance”
The significance of Barrett’s oesophagus is that it may lead to the development of low-grade dysplasia, high-grade dysplasia, or oesophageal adenocarcinoma. Endoscopic surveillance every 1-2 years is often recommended
A previously healthy 45-year-old woman has lump in her right breast. She comes to her primary care physician at the clinic for evaluation and undergoes a fine needle aspiration, which shows malignant cells. She is sent for a core biopsy, which shows invasive carcinoma of the breast. She is referred to a surgeon but refuses to go because her religious beliefs prevent her from undergoing surgery, radiation, or chemotherapy or from taking hormonal therapy. Her primary care physicial discusses all of the potential outcomes of her disease, including death, and the risks and benefits of her decision. She says that she fully understands her condition and the consequences of her choice. A psychiatrist finds that she is competent. She is married and has a 12-year-old daughter. A meeting with the whole family proves that they all agree that surgery, radiation, chemotherapy, and hormonal therapy are not acceptable treatments. The physician believes that the patient is making a huge mistake. Which of the following is the most appropriate next step in management on the part of the physician?
- Call the clinic’s attorney to obtain a court order for surgery
- Contact the chairman of the surgery department to have her override the patient’s refusal
- No further steps are necessary
- Send the patient to another primary care physician because each party’s views on this matter differ so dramatically
- Send the patient to another psychiatrist to confirm that she is indeed competent
No further steps are necessary
Competent, informed patients can refuse recommended interventions. In such cases, it is important for the physician to document in the patient’s’ charts that they were informed of the potential risks of refusing treatment.
A 54-year-old man comes to his physician for a consultation. The patient is concerned that he may have gotten some “disease” from blood. He has read in the newspapers and seen on TV that people who get blood transfusions can get “disease,” and he received a transfusion in 1982. The patient has been a patient in this office for a few years, and his only other past medical history is hypercholesterolaemia and hypertension, for which he is being treated with pravastatin and hydrochlorothiaxzide. He has no abdominal pain, fever, night sweats, or jaundice. Which of the following is the most appropriate screening test?
- Hepatitis B
- Hepatitis C
- HIV
- PPD skin testing
- Rapid plasma reagin testing
HIV
It is generally accepted that the blood supply from 1978 to 1985 was likely to be tainted with HIV positive blood. Patients with a history of blood transfusions during these years, even if currently asymptomatic, should be screened.
PPD: reserved for health care workers, alcoholic, IV drug abusers, diabetics, and end-stage renal patients.
RPR: detect syphilis
A 50-year-old man consults a physician because he has been having transient periods of rapid heart beat accompanied by sweating, flushing, and a sense of impending doom. Physical examination is unrevealing, with no evidence of arrhythmia at the time of the exam. However, the man’s wife is a nurse, so the physician asks that she take vital signs the next time one of the episodes occur. She does, and demonstrates a BP of 195/140 with pulse of 160 during the episode. She promptly takes her husband to the ED but the spell is over by the time that he is seen. Urinary measurement of which of the following would most likely be diagnostic in this case?
- Dehydroepiandrosterone
- Human chorionic gonadotropin
- 17-ketosteroids
- Vanillylmandelic acid
- Zinc protoporphyrin
Vanillylmandelic acid
Suspect pheochromocytoma, most often found in adrenal medulla
Urinary metabolites of epinephrine and norepinephrine are vanillylmandelic acid (VMA) and homovanillic acid
DHEA: produced by adrenal cortex rather than medulla, and measured in serum
17-ketosteroids: evaluation of congenital adrenal hyperplasia (disorder of adrenal cortex)
A 31-year-old professional bodybuilder comes to the physician complaining of 3 weeks of worsening fatigue, low-grade fevers, and myalgias, as well as the gradual onset of jaundice over the past week. He admits to unprotected anal sex 3 months earlier after a championship bodybuilding event. He denies any other homosexual activities. He has no other medical problems and is on no medications. On physical examination, he appears acutely ill, with a temperature of 39.3 C, BP 116/60, and pulse 114. He is deeply icteric and has multiple excoriations over his entire body. His liver edge is smooth and very tender and measures 14cm in the midclavicular line. There is no shifting dullness, and a spleen tip is palpable 4cm below the left costal margin. Stool is brown and negative for occult blood, and there is no peripheral oedema. Which of the following laboratory findings would most likely indicate the worst prognosis?
- Prothrombin time of 19.6s
- AST 983 U/L
- ALT 13,420 U/L
- Total bilirubin 27.4 mg/dL
- White blood cell count of 18,400 mm3
PTT 19.6s
Suspect acute hepatitis, with risk factors for Hep B
Findings of a coagulopathy or encephalopathy confer the worst prognosis in patients with an acute viral hepatitis.
Although transaminases may rise, they are not of prognostic value in viral hepatitis.
A 59-year-old man is seen by a specialist because of chronic, intractable, sinusitis. The decision is made to treat the patient surgically, with evacuation of sinus contents and dilation of the sinus ostia. The material removed is sent routinely for pathologic examination.. An unexpected finding is the presence of fungi with broad, nonseptate, irregularly shaped hyphae. Subsequent review of the patient’s chart reveals a long history of poorly controlled diabetes mellitus. Which of the following is the most likely causative organism?
- Aspergillus
- Blastomyces
- Candida
- Rhizopus
- Sporothrix
Rhizopus
Rhinocerebral mucormycosis, which can be caused by fungal species including Rhizopus, Rhizmucor, Absidia, Basidiobalus. Predisposing conditions include immunosuppression, uncontrolled diabetes mellitus, and patients using the iron-chelating drug desferrioxamine.
Although rare, these infections have a tendency to become fulminant and are frequently fatal
Rx: antibiotic IV amphotericin B +/- surgical embridement
Aspergillus: narrow hyphae
Blastomyces: usually involves lung and is yeast form
Candida: narrow hyphae and is yeast form
Sporothrix: usually infects skin and is yeast form
A 5-day-old boy who was born at home is being evaluated in the urgent care clinic for bruising and gastrointestinal bleeding. Laboratory findings include partial thromboplastin time and prothrombin time greater than 2 minutes; serum bilirubin 4.7 mg/dL; alanine aminotransferase 18 mg/dL; platelet count 330,000/mm3; and haemoglobin 16.3 g/dL. His mother has Factor V Leiden deficiency. Which of the following is the most likely cause of the boy’s bleeding?
- Factor VIII deficiency
- Factor IX deficiency
- Idiopathic thrombocytopenic purpura
- Liver disease
- Vitamin K deficiency
Vitamin K deficiency
Haemorrhagic disease of the newborn as a result of vitamin K deficiency – now uncommon due to routine administration of 0.5-1.0mg of vitamin K within the first hour of birth but is still encountered in situations in which babies are born outside of the hospital. Bleeding is severe and occurs most commonly on the 2nd or 3rd day of life.
A 62-year-old man with hypertension and angina has severe retrosternal chest pain radiating to the left shoulder on awakening, accompanied by diaphoresis and nausea. The pain is not relieved by sublingual nitroglycerin. An ECG is consistent with an evolving anterior wall myocardial infarction. Two days later, the patient develops severe shortness of breath. His temperature is 36.7 C, BP 100/60, pulse 105, and RR 29. Physical examination reveals bilateral wet crackles in the lungs and a holosystolic murmur heard at the apex radiating to the left axilla. A review of his medical records indicates that no murmur was heard during an examination 4 months earlier. Which of the following complications has most likely occurred?
- Aortic dissection
- Cardiac rupture
- Papillary muscle rupture
- Septal perforation
- Ventricular aneurysm formation
Papillary muscle rupture
Occurs in <5% of patients with AMI – usually presents with acute onset of CCF 1-7 days after infarction. A loud systolic murmur is heard at the left sternal border and ECG shows flail mitral valve. Rx: surgical repair/replacement
Aortic dissection: sudden onset of severe chest pain radiating to the abdomen and back. Auscultation is significant for murmur of aortic insufficiency, pulses may be absent or asymmetric.
Cardiac rupture: usually rapidly fatal
Septal perforation: <1% of patients following AMI. Holosystolic murmur along the left sternal border, commonly accompanied by thrill.
Ventricular aneurysm formation: may gradually enlarge over several weeks
A 19-year-old college freshman comes to the university health clinic because of recurrent episodes of wheezing during basketball practices. He has been a starting shooting guard for this team and has usually been hampered by shortness of breath shortly after beginning practice and during games. The symptoms are accompanied by a nonproductive cough and chest tightness. He denies and symptoms at rest. The symptoms occur whether the practices are indoors or outdoors. On physical examination, he is comfortable and denies any symptoms. His physical examination is unremarkable. Which of the following cells are most likely to mediate his symptoms?
- Eosinophils
- Lymphocytes
- Mast cells
- Monocytes
- Neutrophils
Mast cells
Suspect exercise-induced asthmam due to mast cell release of histamines
Rx: prophylactic administration of inhaled cromolyn
Eosinophils: allergen-induced asthma
A 64-year-old patient with a long history of “heart burn” comes to the ED with 6 episodes of haematemesis. He denies alcohol use, smoking, or drug use. He also denies significant nonsteroidal antiinflammatory drug use. He has no known liver disease. His laboratory results are normal with the exception of a haemoglobin of 7.1 gm/dL. He is taken for an emergent oesophageal gastroduodenoscopy, which reveals a gastric ulcer with a bleeding visible vessel. Compared with duodenal ulcer, which of the following statements about gastric ulcers is correct?
- Better response to medication
- Less commonly associated with significant gastrointestinal bleeding
- Lower gastric pH
- More commonly associated with H. pylori
- More commonly associated with malignancy
More commonly associated with malignancy
A 9-year-old boy is brought to the paediatric clinic by his mother, who noticed that the left side of his mouth has started to droop over the past several days. In addition, he is unable to close his left eye completely and complains of it burning. Review of systems reveals a cold approximately 2 weeks ago and recent decreased taste sensation. Physical sensation reveals a well nourished male with normal vital signs. There is left eye ptosis and mild erythema of the left conjunctiva. His smile is asymmetrical on the left. Laboratory evaluation, including a complete blood count and chemistry profile, are normal. Which of the following infections is most closely associated with this patients condition?
- EBV
- Group A Streptococcus
- HIV
- Influenza
- Measles
EBV
Bell palsy: post-infectious allergic or immune demyelinating facial neuritis. EBV is preceding infection in ~20% of cases. 85% of patients have their symptoms resolve on their own over a period of several weeks and 5% have permanent severe facial weakness
A patient with AIDS and a CD4 cell count of 16 comes to medical attention because of the recent onset of motor and sensory neurologic deficits and mental status changes. CSF examination reveals mild lymphocytosis. Neuroimaging studies show multiple ill-defined areas of T2 changes, interpreted as evidence of demyelination. These areas are located in the white matter of both cerebral hemispheres and cerebellum. Which of the following is the most likely diagnosis?
- AIDS-dementia complex
- Cerebral toxoplasmosis
- CMV encephalitis
- Progressive multifocal leukoencephalopathy
- Multiple sclerosis`
Progressive multifocal leukoencephalopathy (PML)
The history of severe HIV-related immune compromise and evidence of destruction of myelin at multiple sites in the CNS points to PML. This condition is caused by JC virus – a parvovirus that produces asymptomatic infections in immunocompetent hosts.
AIDS-dementia complex: no focal brain lesions, progressive dementia, often associated with incontinence and disorientation
Cerebral toxoplasmosis: round, well-circumscribed lesions that shows a peripheral rim of contrast enhancement
CMV encephalitis: predilection for periventricular gray matter and ependyma, as well as the retina
MS: does not develop in the context of immune impairment; demyelinating plaques are typically well-demarcated and most commonly located in periventricular regions
A 20-year-old college football player is rushed to the ED after being knocked unconscious during a training session. The accident occurred when a linebacker accidentally head butted the patient during a pass rush. He was “out of it” for approximately 2 minutes. Although the other player was “shaken-up,” he sustained no serious injuries. Currently he cannot remember any of the events just before the accident or just after the accident. He complains of a severe headache and tingling in his left hand. His temperature is 37 C, BP 110/60, pulse 73, and RR 18. He is in mild distress. There is a contusion above his right eye but no other signs of trauma. Neurologic examination reveals a slight decrease in strength in his left eye but is otherwise within normal limits. Which of the following is the most appropriate next step in management?
- CT scan of head
- Intubation, hyperventilation, and mannitol
- Reassurance, acetaminophen, and observation in hospital overnight
- Reassurance, acetaminophen, and periodic neurologic checks at home
- Skull x-rays
CT scan of head
Suspect epidural or subdural haematoma
A 75-year-old man is brought to the physician by his daughter because of “forgetfulness and “disorientation” that has been gradually worsening over the past 2 years. She is concerned that he may leave the house and get lost. HE has been confused and disorientated from time to time, but last week on 2 occasions he left the house and the neighbours found him in the street. He is forgetful, misplaces things, and often gets confused when he tries to dress himself. He often insists that he has taken a bath when in fact he has not. The family has to take care of his bills because he can no longer manage his money. He has not suffered any major illnesses in the past. A complete evaluation rules out thyroid disease, metabolic and endocrine disorders, depression, drug effects, vitamin deficiencies, vascular disease, infectious disease, and normal pressure hydrocephalus. MSE reveals cognitive deficits. Which of the following neurotransmitters’ activity is most likely deficient in this patient?
- Acetylcholine
- Dopamine
- Glutamate
- Norepinephrine
- Serotonin
Acetylcholine
ACh is known to modulate attention, novelty seeking, and memory by way of basal forebrain projections to cortex and limbic structures. In Alzheimer dementia there is a deficit of ACh, causing cognitive deficits.
Dopamine: Parkinson disease and related subcortical dementias
Glutamate: formation of long-term memory – stroke, seizures, and neuronal cell death
Norepinephrine: modulates sleep cycles, mood, appetite, and cognition
Serotonin: mood disorders
A 10-year-old girl is brought to the physician by her parents. She was recently diagnosed with generalised tonic-clonic epilepsy during a clinic visit that her grandmother took her to. Both of her parents are concerned with the diagnosis and are seeking advice regarding what they should do when the child has a seizure. Which of the following suggestions is appropriate?
- Call an ambulance immediately as soon as seizure begins
- Put something in the child’s mouth at onset of seizure
- Try to place the child on her side during the seizure
- Try to restrain the child during the seizure
- Do not allow the child to return to her activities after recovery
Try to place the child on her side during the seizure
During a seizure episode DO: - Place the patient on their side
- Put a pillow/soft object under head
- Loosen tight clothing around the neck
- Remove sharp objects from surroundings
DON’T: - Put any object into patient’s mouth
- Call ambulance unless lasts >10 mins
- Try to restrain the patient
After the seizures, remains with the patient until he/she is full alert and allow him/her to return to usual activities.
A 29-year-old man is brought to the ED in a comatose state a few hours after complaining of sudden onset of excruciating headache. His friend does not know if the patient has any underlying medical conditions. Neurological examination reveals dilated pupils poorly responsive to light. A CT scan of the head without contrast demonstrates hyperdensity within the suprasellar cistern, while MRI is unremarkable. Lumbar puncture shows haemorrhagic CSF. Which of the following is the most likely diagnosis?
- Amyloid angiopathy-related haemorrhage
- Caverous sinus thrombosis
- Haemorrhagic infarction
- Pituitary apoplexy
- Ruptured berry aneurysm
Ruptured berry aneurysm
Rupture of berry aneurysm is most common cause of subarachnoid bleeding
Suprasellar cistern: CSF-filled space located above sella turcica, under the hypothalamus – contains optic chiasma, infundibular stalk and polygone of Willis.
A 3-year-old girl is being evaluated for developmental delays. Her parents report that the pregnancy was uneventful and that the delivery was without complications. The girl reached all milestones normally during the first year. Length, weight, and head circumference were all well within the normal range during the first year. During her second year, the paediatrician noticed deceleration of head growth, and her parents noticed a gradual decline in her fine motor abilities, frequent hand-wringing movements, and loss of social engagement. Her movements became poorly coordinated. Which of the following is the most likely diagnosis?
- Asperger disorder
- Attention-deficit/hyperactivity disorder
- Autistic disorder
- Pervasive developmental disorder, not otherwise specified
- Rett syndrome
Rett syndrome
Durign the first 5 months after birth, the infant has age-appropriate motor skills, head circumference, growth, and social interactions. At 6-30 months, the child has progressive encephalopathy with decline in previously developed motor and social skills.
Pervasive developmental disorder, not otherwise specified is a diagnostic category that would be used when a child manifests a qualitative impairment in the development of reciprocal social interaction and communication but does not meet the criteria for other pervasive developmental disorders.
A 40-year-old man is admitted to hospital for evaluation and treatment of depression associated with suicidal thoughts. He denies any past psychiatric history. His medical history is significant for hypertension, for which he currently takes hydrochlorothiazide. He also describes a history of once having a painful erection that lasted for 8 hours and had to be treated with intracavernous injections in the ED. He states that this was thought to be related to an antihypertensive medication that he used to take. During the treatment of the man’s psychiatric condition, which of the following medications should be avoided?
- Buproprion
- Clonazepam
- Paroxetine
- Trazodone
- Zolpidem
Trazodone
Older antidepressant that has significant alpha-adrenergic blocking properties and has been associated with priapism (persistent, painful penile erection)
None of the other medications are associated with priapism
Bupropion: non-tricyclic antidepressant
Clonazepam: long-acting benzodiazepine
Paroxetine: SSRI
Zolpidem: non-benzodiazpine hypnotic agent that acts at GABA-benzodiazepine complex
A 27-year-old successful businesswoman has developed a fear of flying after an extremely rough landing. She is paralyzed with fear and unable to travel for business. Her physician tried giving her lorazepam to take during the flight, but it didn’t help. She returns to the physician and asks if there is anything else that she can do to reduce her fear because she is not getting a promotion at work because she cannot travel. Which of the following is the most commonly used treatment for this disorder?
- Exposure therapy
- Hypnosis
- Insight-orientated psychotherapy
- Medication
- Supportive therapy
Exposure therapy (a type of behavioural therapy)
The patient is desensitised by a gradual exposure to a phobic stimulus.
Insight-oriented psychotherapy was initially used to treat phobies, but analysing unconscious conflicts didn’t resolve phobic symptoms. It does help the patient understand the origins of the phobia and how to deal with anxiety-provoking stimuli.
Medication is only used if a specific phobia is associated with panic attacks and generalised anxiety.
A 19-year-old man comes to the ED after a suicide attempt. He is crying and not entirely coherent, but says that he swallowed most of a bottle of over-the-counter-pain medication about 2-4 hours ago. He thinks the medication was a combination of acetaminophen and codeine, but is uncertain. His BP is 130/76, pulse 74, and RR 18. Physical examination reveals an agitated but well-appearing young man. An initial acetaminophen level is undetectable, although the patient’s urine is positive for opioids. A nasogastric tube is placed, and lavage is started. A nurse is attempting to contact family members to have the pill bottle brought to the hospital. Which of the following is the most appropriate next step in management?
- Admit to monitored unit for observation
- Begin haemodialysis
- Immediately administer N-acetylcysteine
- Recheck acetaminophen level in 2 hours
- Start naloxone infusion
Immediately administer N-acetylcysteine
Should be administered immediately when ingestion is suspected, as the longer the delay in treatment the worse the clinical outcome.
Acetaminophen level should be check in 2 hours, but treatment should be started now.
A 32-year-old woman, gravida 3, para 2, at 14 weeks gestation comes to the physician for a prenatal visit. She has some mild nausea, but otherwise no complaints. She has no significant medical problems and has never had surgery. She takes no medications and has no known drug allergies. She is concerned for two reasons. First, the ‘flu season’ is coming, and she seems to get sick every year. Second, a child at her son’s daycare center recently broke out with welts and was sent home. Which of the following vaccinations should this patient most likely be given?
- Influenza
- Measles
- Mumps
- Rubella
- Varicella
Influenza
Influenza pneumonia during pregnancy can be a severe illness.
The measles, mumps and rubella vaccines are live attenuated vaccines – their used during pregnancy is contraindicated.
The varicella vaccine is a live-virus – it’s use during pregnancy is also contraindicated.
A 19-year-old primigravid woman at 42 weeks’ gestation comes to the labour and delivery ward for induction of labour. Her prenatal course was uncomplicated. Examination shows her cervix to be long, thick, closed, and posterior. The foetal heart rate is in the 140s and reactive. The foetus is vertex on ultrasound. Prostaglandin gel is placed intravaginally. One hour later, the patient begins having contractions lasting longer than 2 minutes. The foetal heart rate falls to the 70s. Which of the following is the most appropriate next step in management?
- Administer general anaesthesia
- Administer terbutaline
- Perform amnioinfusion
- Start oxytocin
Administer terbutaline (tocolytic)
The main complication of prostaglandin in induction of labour is uterine hyperstimulation. This is defined as an increased frequency of contractions (greater than 5 every 10 minutes) or an increased length of each contraction (greater than 2 minutes) with evidence of foetal distress. When this occurs, the patient may be treated with IV/SC terbutaline OR IV magnesium sulfate.
Oxytocin is a prostaglandin gel.
A 32-year-old woman comes to the physicina because of amenorrhoea. She had menarche at age 13 and has had normal periods since then. However, her last menstrual period was 8 months ago. She also complains of an occasional milky nipple discharge. She has no medical problems and takes no medications. She is particularly concerned because she would like to become pregnant as soon as possible. Examination shows a whitish nipple discharge bilaterally, but the rest of the examination is unremarkable. Urine hCG is negative. TSH is normal. Prolactin is elevated. Head MRI scan is unremarkable. Which of the following is the most appropriate pharmacotherapy?
- Bromocriptine
- Dicloxacillin
- Magnesium sulfate
- Oral contraceptive pill
Bromocriptine (dopamine agonist; decreases prolactin levels)
Suspect hyperprolactinaemia, likely coming from a pituitary microadenoma.
If this patient did not wish to become pregnant, the OCP would be appropriate.
A 20-year-old woman comes to the physician because of left lower quadrant pain for 2 months. She states that she first noticed the pain 2 months ago but now it seems to be growing worse. She has had no changes in bowel or bladder function. She has no fevers or chills and no nausea, vomiting, or diarrhoea. The pain is intermittent and sometimes feels like a dull pressure. Pelvic examination is significant for a left adnexal mass that is mildly tender. Urine hCG is negative. Pelvic ultrasound shows a 7cm complex left adnexal mass with features consistent with a benign cystic teratoma. Which of the following is the most appropriate next step in management?
- Repeat pelvic examination in 1 year
- Repeat pelvic ultrasound in 6 weeks
- Prescribe the oral contraceptive pill
- Perform hysteroscopy
- Perform laparotomy
Perform laparotomy and removal of cust – as adnexal masses enlarge the risk of ovarian torsion increases + symptomatic control + pathologic diagnosis
Teratoma (aka dermoid): germ cell tumour consisting of multiple cell types derived from 1 or more of the 3 germ layers. Germ cell tumours are the most common type of ovarian neoplasm in females <20 and dermoids are the most common benign type.
http://emedicine.medscape.com/article/281850-overview
A 34-year-old woman comes to the clinic for evaluation of chronic constipation. She has one bowel movement every week and often suffers lower abdominal fullness and distension. Over-the-counter bowel remedies help somewhat, but she is concerned that something more serious may be going on. Her constipation has been chronic but has been worse over the last 2 years.
Aside from constipation, she reports no other gastrointestinal problems and generally feels quite healthy. In addition to her current problem, she was diagnosed with gestational diabetes while pregnant with her fifth child 2 years ago and also suffers occasionally urinary incontinence. Family history is remarkable for a sister with irritable bowel syndrome and an uncle who died of colon cancer at age 65. Physical examination, routine chemistries, and a complete blood count are within normal limits. Given this patient’s presentation, which of the following is the most likely explanation for this woman’s constipation?
- Abnormal anorectal sphincter tone
- Autonomic neuropathy
- Functional or idiopathic constipation
- Left-sided colonic mass
- Right-sided colonic mass
Abnormal anorectal tone i.e. pelvic floor dysfunction
Suspect in multiparous women.
Autonomic neuropathy: common in patients with diabetes and can manifest as diabetic gastroparesis.
A 17-year-old girl is referred for evaluation because of persistent headaches for the past 3 months and diminished peripheral vision first noticed 2 weeks ago. On physical examination she is short for her age. She has fully developed breasts but no axillary or pubic hair. She started menstruating 2 years ago but has irregular periods. She has no libido. The absence of axillary and pubic hair in this girls is indicative of which of the following conditions?
- Excessive production of androgen
- Excessive production of oestrogens
- High blood levels of prolactin
- Insufficient production of androgens
- Insufficient production of oestrogens
Insufficient production of androgens.
In both men and women, growth of axillary and pubic hair is stimulated by androgens. They are also responsible for libido.
High levels of prolactin: produce galactorrhoea and amenorrhoea.
A 40-year-old man is brought in for evaluation by the Coast Guard after the small plane he was piloting crashed into the ocean. The man’s wife and two friends were also on the place. The man has survived the crash with cuts and a broken arm, but he claims he has no memory of the crash or how he escaped the plane. He is also unable to explain how he got his life jacket on. His physical examination now is significant only for minor lacerations and a fractured right humerus, and he has no alteration in consciousness. A CT scan is normal. He is very upset that the fate of his wife is unknown, and he has nightmares for the next several nights while trying to sleep. Which of the following is the most likely diagnosis?
- Dissociative amnesia
- Dissociative fugue
- Dissociative identity disorder
- Factitious disorder
- Transient global hypoxia
Dissociative amnesia
Extremely stressful event followed by localised loss of memory or amnesia of circumstances surrounding the event. Often accompanied by nightmares and anxiety concerning the event.
Dissociative fugue: disturbance of identity that requires a sudden, unexpected travel away from home or one’s place of work, with inability to recall one’s past
Dissociative identity disorder: presence of 2 or more distinct identities or personality states, whcih reucrrently take control of the person’s behaviour
Factitious disorder: intentional production of symptoms and gratification from assuming the sick role
A 54-year-old woman comes to the physician for an annual examination. She has no complaints. For the past year, she has been taking tamoxifen for the prevention of breast cancer. She was started on this drug after her physician determined her to be at high risk on the basis of her strong family history, nullipariety, and early age at menarche. She takes no other medications. Examination is within normal limits. Before she leaves the exam room she expresses concern about the longterm effects of tamoxifen. Which of the following is this patient most likely to develop while taking tamoxifen?
- Breast cancer
- Elevated LDL cholesterol
- Endometrial changes
- Myocardial infarction
- Osteoporosis
Endometrial changes (polyp formation, hyperplasia, frank invasive carcinoma)
Tamoxifen: NSAID with pro- and antioestrogenic properties (antioestrogenic at the breast, but proestrogenic at the endometrium)
A 14-year-old boy is evaluated for short stature. He has no significant past medical history and is considered otherwise healthy by his parents. He eats a normal diet and has regular meals. His height and weight have been consistently at the 5th percentile since early childhood. His physical examination is normal, with genitalia at Tanner stage 3. Which of the following is the most likely laboratory finding for this boy?
- Bone age that is equivalent to chronological age
- Decreased complement C3 level
- Decreased serum albumin concentration
- Decreased thyroid stimulating hormone
- Increased serum creatinine concentration
Bone age that is equivalent to chronological age
Suspect familial short stature (FSS): usually haven normal birth weight and length but at the age of 2-3 their growth begins to decelerate and drops to around the 5th percentile
A 19-year-old woman comes to the ED after a syncopal event. While working in the garden, she accidentally disturbed a wasps’ nest and was stung on her right hand. She has never been stung before and does not know if she needs treatment. The woman tried to rest at home but felt extremely ill and called for an ambulance. She currently complains of dizziness and has some swelling in both of her hands and feet. Vital signs are: temperature 37.8 C, BP 83/40, pulse 130, and RR 22. Oxygen saturation, obtained with a pulse oximeter, is 97% on room air. Lung auscultation reveals a diffuse mild wheeze. Which of the following is the first priority in caring for this patient?
- Administer epinephrine
- Bolus patient with 500 cc of half-normal saline
- Perform endotracheal intubation
- Prescribe diphenhydramine and cimetidine
- Start IV corticosteroids
Administer epinephrine
Patient shows signs of anaphylactic shock and epinephrine can reverse both hypotension and bronchospasm.
Fluid bolus is required, but normal saline rather than hypotonic fluid
Diphenhydramine: antihistamine
Cimetidine: histamine H2-receptor antagonist
Steroids will prevent the late phase reaction, however this is a delayed effect.
The longtime primary care physician of an 85-year-old woman is asked to help mediate care between the family and the hospital’s medical service. The patient sustained an anoxic brain injury during an in-hospital cardiac arrest one week ago in which the patient had a pulseless period for at least 5 minutes. On physical examination, her vital signs are normal and stable with the assistance of continuous mechanical ventilation. Pupillary and corneal reflexes are present bilaterally. There is episodic decorticate rigidity, but no purposeful movement present. An EEG suggests severe, diffuse cortical damage. The patient’s husband asks the physician if she is brain dead. Which of the following is the most appropriate response?
- It is too early to predict brain death by the legal definition
- The diagnosis of brain death can only legally be made by a neurologist
- The decision on brain death must await the completion of MRI
- The presence of brain stem function and posturing rules out brain death, but the examination findings and supportive data suggest extensive brain damage
- The suggestion of severe cortical damage by EEG implies brain death
The presence of brain stem function and posturing rules out brain death, but the examination findings and supportive data suggest extensive brain damage
A 55-year-old woman with COPD presents to the GP because of an exacerbation of her cough and dyspnoea. On physical examination, her BP is 126/64, pulse 82, and RR 24. On lung examination, there are loud expiratory wheezes and rhonchi. The cardiac examination is normal. An arterial blood gas is performed. Which of the following results would most likely be expected?
- pH 7.2; pCO2 60; pO2 46
- pH 7.3; pCO2 50; pO2 94
- pH 7.35; pCO2 45; pO2 60
- pH 7.46; pCO2 25; pO2 76
- pH 7.52; pCO2 30; pO2 82
pH 7.35; pCO2 45; pO2 60
Acute exacerbation of COPD
Expect compensated respiratory acidosis because of CO2 retention, and mild hypoxia
With respirations of 24 (high, but not extremely high) she would not be expected to show the severe levels of acidosis and CO2 retention to cause pH 7.2; pCO2 60; pO2 46.
Although asthmatic may present during an acute exacerbation with respiratory alkalosis, in a patient with underlying COPD there is usually a baseline respiratory acidosis.
An AIDS patient undergoes endoscopy for chronic substernal pain that is exacerbated when he swallows. The studies demonstrate inflammation and superficial ulceration of the distal oesophagus. Biopsies taken from the area shown inflammation and a few cells, particularly in the endothelium of small blood vessels, with markedly enlarged, smudgy, eosinophilic nuclei. Which of the following is the most likely cause of the patient’s oesophagitis?
- Acid reflux
- Candida
- CMV
- Herpes simplex
- Herpes zoster
CMV
Causative agents of infectious oesophagitis in immunosuppressed patients are typically Candida, Herpes simplex, or CMV. There may be >1 agent present.
CMV: histologically small numbers of cells with markedly enlarged nuclei, which may show both cytoplasmic and nnucelar viral inclusions. Rx: ganciclovir.
Acid reflux: would not alter nuclear morphology
Candida: hyphal and yeast forms.
Herpes simplex: multinucleated cells with nuclear viral inclusions
Herpes zoster: resemble herpes simplex but it much less commonly involves the oesophagus.
A 40-year-old woman is evaluated by a dermatologist because she has many pigmented lesions on her body. Examination of the skin and scalp demonstrates over 100 individual lesions, most of which vary in size from 5-12 mm. They are found all over her body, but most commonly on sun-exposed skin. They are predominantly round in shape, but some have subtly notched borders or are slightly asymmetrical. The woman’s entire skin surface is photographed, and when the photographs are repeated 6 months later, no change in appearance of any of the lesions is noted. Which of the following is the most likely diagnosis?
- Compound nevi
- Dysplastic nevi
- Halo nevi
- Lentigos
- Malignant melanomas
Dysplastic nevi: intermediate category between obviously benign nevi and malignant melanoma. They do have an increased rate of progression to melanoma
Compound nevi: usually dark, typically elevated, 3-6mm with very regular shape
Halo nevi: flesh-coloured or dark nodules, usually 3-5mm, surrounded by a ring of depigmented skin
Lentigo: flat, sharply marginated, uniformly pigmented, 2-4mm diameter
A 60-year-old woman consults a physician because of weakness, headaches, dizziness, and tingling in her hands and feet. Physical examination demonstrates multiple areas of bruising on the back of her forearms and shins. On specific questioning, she reports having had five nosebleeds in the past 2 months, which she had attributed to “dry air”. Blood studies are drawn which show a platelet count of 1,200,00/nanoL, RBC 5,100,000/nanoL, and WCC 10,500/nanoL with a normal differential count. Review of the peripheral smear demonstrates many abnormally large platelets, platelet aggregates, and megakaryocyte fragments. No abnormal red or white blood cells are seen. Philadelphia chromosome studies are negative. Which of the following is the most likely diagnosis?
- Chronic myelogenous leukaemia
- Myelofibrosis
- Polycythemia vera
- Primary thrombocythemia
- Secondary thrombocythemia
Primary (essential) thrombocythemia
Condition is due to a clonal abnormality of a multipotent haematopoietic cell that produces megakaryocytic hyperplasia with resultant increased platelet count. Since the platelets are often abnormal, either a thrombotic or a haemorrhagic tendency may be seen.
CML: associated with of Philadelphia chromosome or markedly increased WCC
Myelofibrosis: would likely show some abnormally shaped (often tear drop) red cells
Polycythemia vera: associated with increase RBC mass
Secondary thrombocythemia: reactive process that may occur in a variety of settings. Abnormal platelet forms are not usually seen and platelet function tests are usually normal.
The intern rotating through the newborn nursery becomes concerned when after 30 hours, a newborn infant has not passed meconium. He was full term with a birth weight of 3856g. The pregnancy was uncomplicated. The baby appears well with no respiratory distress. Slight abdominal distension is noted. Rectal examination reveals a slightly tight rectum and results in a greenish gush of stool. Which of the following tests will probably confirm the likely diagnosis?
- A stool culture
- A rectal biopsy
- A barium enema
- An alpha 1-antitrypsin level
- A serum TSH level
Rectal biopsy
Suspect Hirschsprung disease or congenital aganglionic megacolon: caused by congenital absence of the ganglion cells of both the Meissner and Auerbach plexuses. Rx: surgical
A barium enema may be indicated in suspected cases of Hirschprung disease, but the biopsy is diagnostic. In this case it would reveal a dilated proximal bowel with evidence of a contracted distal rectum
Alpha 1-antitrypsin deficieny: jaundice, acholic stools, hepatomegaly
Hypothyroidism: constipation, lethargy, poor feeding, mottling, prolonged jaundice
A 72-year-old African American man with a history of renal dysfunction, congestive heart failure, and previous myocardial infarction is currently undergoing dialysis. Until the past few weeks, he has been in good spirits and has a strong family support system that helps him in getting to and from dialysis daily. Over the past few weeks, however, he has been feeling increasingly depressed and has begun to act bizarrely, with persecutory delusions that the government is poisoning the chemicals used on him for dialysis. Also in the last few weeks, due to increased stomach pain, his medications have been adjusted and now include cimetidine for stomach ulcers, digoxin, and a baby aspirin daily. He also takes docusate sodium as needed for stool softening and ibuprofen as needed for mild arthritis pain. Which of the medications would be most likely to have induced the symptoms the patient is now experiencing?
Cimetidine: known to cause psychiatric effects of clinical significance, including delusions and psychosis. Rx: reduce dosage
Digoxin has been known to cause delirium in toxic levels, but does not cause the long standing delusion that this patient demonstrates.
A 22-year-old woman, gravida 2, para 0, at 8 weeks’ gestation comes to the physician for a prenatal visit. She has no complaints. Her first pregnancy resulted in a 22-week loss when she presented to her physician with bleeding from the vagina, was found to be fully dilated, and delivered the fetus. Examination of the patient today is unremarkable. She declines to have a cerclage placed. When should this patient begin having regular cervical examinations?
- 10 weeks
- 16 weeks
- 22 weeks
- 28 weeks
16 weeks
Obstetrical history is consistent with cervical incompetence, which is a cause of second-trimester miscarriage/preterm. Increased risk in those who have had previous trauma to the cervix (e.g. dilation of cervic, cervical conisation, obstetric trauma), women with mullerian anomalies, or history of in-utero exposure to diethylstilbestrol. Rx: cerclage (suture at the level of internal os) between 12-16 weeks gestation.
A 64-year-old man smokes one or two cigarettes a day sporadically on weekends and he has been diagnosed with severe emphysema. His pulmonologist, on examining his routine blood work, finds elevated serum transaminases. Hepatitis serologies reveal no evidence of viral hepatitis A, B, or C. A younger brother died of emphysema at age 50 and has no smoking history. Which of the following diseases should most likely be considered to explain this patient’s liver abnormalities AND his lung disease?
- Alpha-1-antitrypsin deficiency
- Primary haemochromatosis
- Primary sclerosing cholangitis
- Secondary haemachromatosis
- Wilson disease
Alpha-1-antitrypsin deficiency
Decreased A1AT activity in blood and lungs, and deposition in the liver
Primary haemochromatosis: autosomal recessive, leaves iron deposition in liver, heart, and pancreas, and leads to bronze hyperpigmentation of the skin.
Primary sclerosing cholangitis: occurs in patients with ulcerative colitis and does not affect the lungs.
Secondary haemochromatosis: occurs in patients who have received massive amounts of blood transfusion over the years.
Wilson disease: familial genetic liver disease and also involves the eye (Kayser-Fleischer ring) and causes neuropsychiatric disorders.
A 28-year-old man who recently emigrated from Italy returns to the physician’s office for a follow up visit to evaluate his anaemia. Four days ago, he presented with fatigue and dyspnoea on exertion and was found to have a haemocrit of 22%.
At the time he was admitted to the local hospital for evaluation. Laboratory analysis shows: haematocrit 23%; MCV 59 microm3; reticulocyte count 4.3%; serum iron 160 microg/dL; total iron binding capacity (TIBC) 230 microg/mL; serum ferritin 80 nanog/mL; haemaglobin electrophoresis shows absent beta bands.
Which of the following is the most likely diagnosis?
- Alpha-thalassaemia
- Beta- thalassaemia
- Iron deficiency anaemia
- Megaloblastic anaemia
Beta-thalassaemia
Key words: microcytic anaemia, Mediterranean descent, absent beta bands
A worried 19-year-old single mother calls the physician because her 5-day-old son has developed red eyes, tearing, and a yellow, sticky discharge that prevents him from opening his eyes after sleeping until she cleans it off. The baby was born at full term by vaginal delivery and scored 9 and 9 on the Apgar scale. The physical examination at the time of birth was within normal limits. Mother and son were discharged after 24 hours and everything was going well until this happened. This is her first child and she does not know whether specific treatment is required or the condition will resolve on its own. The physician advises the mother to bring the newborn in and a couple of hours later they arrive at the office. On physical examination, the neonate does not seem to be in distress. He has bilateral prominent tearing, conjunctival injection, substantial lid oedema, and a purulent discharge. A Gram stain of the purulent material reveals gram-negative diplococci. Which of the following is the most appropriate treatment for this patient?
- Topical erythromycin
- Topical silver nitrate
- Topical vidarabine
- Systemic ceftriaxone
- Systemic erythromycin
Systemic ceftriaxone + frequently irrigate eyes with saline
Dx: gonococcal conjunctivitis. Can occur at birth or after 5 days of age if the patient has received topical antibiotic prophylaxis at birth.
Neisseria gonorrhea and chlamydia trachomatis are common infectious causes acquired by passage through the birth canal. Chlamydia is the most common cause of infectious ophthalmia neonatorum.
Chlamydia conjunctivitis: appears 5-23 days after birth
Bacteria, such as haemophilus, streptococcus, staphylococcus, or pneumococcus usually cause acute purulent conjunctivitis.
Viruses (adenovirus, enterovirus) may cause an isolated conjunctivitis.
Allergic conjunctivitis usually develops after the neonatal period.
A 50-year-old man is admitted secondary to respiratory failure and tachycardia. His temperature is 38.9 C, BP 110/60, and RR 30. His ECG shows P waves preceding the QRS complex. No two P waves have the same morphology. Which of the following is the most appropriate next step in management?
- Administration of digitalis (digoxin)
- Administration of warfarin
- Electrical cardioversion
- Mechanical ventilation
- Placement of a defibrillator
Mechnical ventilation
Dx: multifocal atrial tachycardia: variable P wave morphology and PR and RR intervals. Control of this tachycardia comes with improved ventilation and oxygenation. Caused by multiple sites of competing atrial activity and assoc. with severe pulmonary disease.
Digitalis/digoxin: enhances myocardial contractility in heart failure and rate control in AF
Warfarin: chronic AF
Electrical cardioversion: AF (must be first adequately anticoagulated)
Defibrillation: arrhythmia and haemodynamically unstable (ventricular fibrillation and tachycardia)
A 54-year-old heavy smoker comes to the ED because of a mild cough, chest pain, diarrhoea, fatigue, headache, and fever for 3 days. He has a scant amount of nonpurulent sputum. Several of his coworkers are experiencing similar symptoms. His temperature is 39.8 C, BP 120/80, and pulse 50. Rales are heard of auscultation. Diffuse abdominal tenderness is present. A chest x-ray film reveals bilateral infiltrates. A Gram stain of his sputum shows numerous neutrophils, but no organisms. A sputum culture on buffered charcoal yeast extract (BYCE) agar grows gram-negative bacilli. Which of the following is the most likely pathogen?
- Chlamydia trachomatis
- Legionella pneumophila
- Moraxella carrhalis
- Mycoplasma pneumoniae
- Pneumocystis carinii
Legionella pneumoniae (Legionnaire’s disease)
Often acquired from a contaminated water supply (air conditioning systems) and can lead to outbreaks. Rx: erythromycin
Chlamydia trachomatis: obligate intracellular parasite with features similar to gram-negative bacteria
Moraxella catarrhalis: gram-negative coccus that causes pneumonia in elderly patients with COPD
Mycoplasma pneumoniae: CAP that occurs in young adults; CXR shows interstitial infiltrates
Pneumocystis carinii: opportunistic pathogen that causes pneumonia in immunocompromised patients; CXR shows diffuse interstitial infiltrates
A 63-year-old man with a history of noninsulin-dependent diabetes and hypertension comes to the physician after being awakened from sleep by severe pain in his right first toe. He reports the sudden onset of acute pain in the toe, rapidly followed by erythema, swelling, tenderness, and warmth. His temperature is 37 C, BP 170/60, pulse 97, and RR 19. Physical examination is normal except for swelling and severe tenderness over his metatarsophalangeal joint on the right foot. Which of the following is the most appropriate first-line treatment for this patient’s condition?
- Allopurinol
- Dietary modifications
- Indomethacin
- Prednisone
Indomethacin (NSAID)
Dx: gout
Allopurinol: prevent gout recurrences by decreasing uric acid levels
Dietary modifications: long-term prevention of recurrences
Prednisone: effective medication in treatment of acute gout, but is not first-line due to side effects
An 18-year-old man comes to the physician for a health maintenance examination. He has a family history of Tangier disease, and a number of adults in his family have either hepatosplenomegaly, recurrent polyneuropathy, or both. He has no specific complaints at this time. Which of the following would be the strongest finding on physical examination to suggest the presence of this disease?
- Angiokeratomas
- Grey-brown pigmentation of the forehead, hands, and pretibial region
- Irregular black deposits of clumped pigment in the peripheral retina
- Orange-yellow tonsillar hyperplasia
- Pingueculae
Orange-yellow tonsillar hyperplasia
Tangier disease: rare familial disorder characterised by alpha-lipoprotein deficiency, leading to very low high-density lipoprotein (HDL), recurrent polyneuropathy, lymphadenoapthy, and hepatosplenomegaly due to storage of cholesterol ester in reticuloendothelial cells
Multiple angiokeratomas on lower half of the body: Fabry disease
Grey-brown pigmentation of forehead, hands, and pretibial region: Gaucher disease
Irregular black deposits of clumped pigment in peripheral retina: retinitis pigmentosa
Pingueculae (conjunctival degeneration- yellow-white deposit adjacent to limbus (similar to pterygium)): Gaucher disease/normal
A 6-month-old boy is brought in to the ED by his mother who states that when she picked him up from the babysitter he was not acting right. The babysitter stated that he was sleeping more and was fussy. On examination the baby is stuporous (dazed). His temperature is 37.8 C, pulse 140, and RR 36. A 4cm eccymosis is noted on his right cheek. The remainder of the examination is unremarkable. The physician suspects possible physical abuse. He orders a CT scan of the head, skeletal survey, chemistry panel, and complete blood count. Which of the following diagnostic tests should also be ordered?
- Ammonia level
- Coagulation studies
- Lipid panel
- Thyroid studies
- Urine electrolytes
Coagulation studies
Dx: shaken infant syndrome
Normal platelet count and coagulation studies eliminates the misdiagnosis of bleeding abnormalities
A 73-year-old white man with benign prostatic hyperplasia and no past psychiatric history comes to the physician for a routine visit. His physical examination and routine laboratory studies are normal. The patient’s wife died approximately 2 months ago after an extended course of colon cancer and since then he has been ‘sad and lonely’. He also indicated that he just recently began to recover weight that he lost in the days and weeks since his wife’s passing. His sleep is also recovering and he has been spending more time with his children and grandchildren. He is troubled, however, by the feeling that he can actually hear his wife calling out his name when he is alone in the house that the couple shared for their entire marriage. Which of the following is the most appropriate next step in management?
- Obtain an electroencephalogram
- Prescribe a short course of antipsychotic medication
- Reassure the patient that he is experiencing a normal grief reaction
- Recommend that the patient have neuropsychologic testing
- Send the patient for an immediate psychiatric evaluation
Reassure the patient that he is experiencing a normal grief reaction. Beyond grief counselling at his own request, there is no further intervention that is absolutely necessary at this time.
A 34-year-old primigravid woman at 30 weeks’ gestation comes to the physician with regular contractions every 6 minutes. Her prenatal course was significant for type 1 diabetes, which she has had for 10 years. Over the course of 1 hour, she continues to contract, and her cervix advances from closed and long to a fingertip of dilation with some effacement. The patients is started on magnesium sulfate, penicillin, and betamethasone. Which of the following is the most likely side effect from the administration of corticosteroids to this patient?
- Decreased childhood intelligence
- Increased maternal insulin requirement
- Maternal infection
- Neonatal adrenal suppression
- Neonatal infection
Increased maternal insulin requirement – corticosteroids are known to lead to more difficult glucose control in diabetic women. BSL should be checked regularly
A 30-year-old woman, G3P3, comes to the maternity unit at 38 weeks’ gestation complaining of regular contractions every 3 minutes for the past hour. Her previous births have been vaginal and uncomplicated. She has received excellent prenatal care and reports having gestation diabetes that was difficult to control during her pregnancy. The delivery is prolonged. She eventually delivers a 4.263 kg boy with Apgar scores of 8 and 9. The woman loses an estimated 600 mL of blood. Intravenous access with a large bore IV is obtained for volume resuscitation. Fundal massage is performed. Despite these interventions, the mother continues to bleed 45 minutes after delivery. Which of the following is the most likely finding on physical examination?
- Inversion of the uterine fundus
- Mucosal bleeding and bruising
- Rupture of the uterus
- Spongy, soft uterus
- Vaginal laceration
Spongy, soft uterus
Uterine atony is the most common cause of postpartum bleeding, and there is increased risk with prolonged labour and large children/twins.
Cervical or vaginal lacerations are common but less likely in a patient with previous deliveries.
A 24-month-old child is seen in the paediatrician’s office for a regular health supervision visit. He has no history of developmental delay, however the mother is concerned because her neighbour’s son ‘seems more advanced’ because he is able to perform more motor function. The patient was born by an uncomplicated normal vaginal delivery at term, and he has not had any significant illness or injury prior to this visit. Which of the following motor milestones is most consistent with his age?
- Building a tower of 2 cubes
- Copying a circle
- Scribbling
- Throwing a ball overhead
- Walking backward
Throwing a ball overhead
Other milestones consistent for 24 months of age are jumping up and kicking a ball forward.
Building a tower of 2 cubes: 14 months (by 24 months should be able to build a tower of at least 6 cubes)
Copy a circle: ~36 months
Imitative scribbling: ~16 months
Spontaneous scribbling: ~18 months
Walk backward: 18 months
A 62-year-old man with a heavy smoking history comes to the ED with chest pain. He states that for the past few months, he has been getting chest ‘pressure’ localised to the substernal region, radiating to the left arm on occasion. The pain occurs with mild exertion, but never at rest. He further states that when he gets the pain, it usually lasts about 5 minutes but goes away with rest. He reports that his exercise tolerance is moderate, and he gets dyspnoea on exertion after a few blocks of walking. On physical examination, he has no chest wall tenderness to palpation, but a carotid bruit is heard and his dorsalis pedis pulses are decreased. He has no history of coronary disease but his family history is significant for his father having a myocardial infarction at age 56. He denies chest pain at this time. In addition to ascertaining his other coronary risk factors, which of the following is the most appropriate diagnostic intervention?
- Obtain a resting ECG
- Schedule the patient for a cardiac echocardiogram
- Schedule the patient for an exercise treadmill test
- Schedule the patient for non-urgent coronary angiography
Exercise treadmill test
Dx: new-onset angina
Suspect severe peripheral vascular disease and coronary artery disease
Resting ECG is not the MOST appropriate given that he is currently pain-free
Echogram is not appropriate in the triaging of suspected ischaemic chest pain
Non-urgent coronary angiography is reserved for people that have had equivocal results from less invasive diagnostic procedures