practiceexam1 & 2

8/10/2019 PracticeExam1 & 2

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brainX Digital Learning System

Study Session of KnowledgeBase: Practice Exam 1

Record 1

! "#$year$old Polis% man comes to t%e clinic for &ainful cal'es after wal(ing long distances and

for discoloration of t%e fingers wit% c%anges in tem&erature) *e says %is sym&toms started two

mont%s ago+ and %e gets no relief from t%e ibu&rofen) *e %as &re'iously been %ealt%y) *e

currently smo(es a &ac( a day and drin(s socially) *e %as no %istory of drug abuse) ,n &%ysical

examination+ %is blood &ressure is 1-./#. mm *g+ %eart rate is 0/min+ and %e is afebrile)

Examination of t%e %ands re'eals distal digital isc%emia and tro&%ic c%anges in t%e nails of bot%

%ands) Radial &ulses are absent bilaterally+ but all ot%er &ulses are &resent) *is rig%t calf s%ows

e'idence of a su&erficial t%rombo&%lebitis) Laboratory studies s%ow: w%ite cell count

#+0../mm"+ %ematocrit ")02+ 345 # 6m"+ ESR -. mm/%+ and 4$!74! as negati'e) 8%e

r%eumatoid factor and !7! are negati'e) 9%ic% of t%e following s%ould be done next for t%is

&atient

;!< *e&arin

;B< Prednisone

;4< !rterial by&ass

;D< 4yclo&%os&%amide

;E< !bstention from tobacco

!nswer:

;E< !bstention from tobacco

Ex&lanation:

8%is &atient %as t%romboangiitis obliterans ;Buerger=s disease


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R%eumatology

Record C

! C?$year$old woman wit% 4ro%n=s disease &resents to your office wit% recurrent abdominal

&ain and diarr%ea) S%e %as been ta(ing mesalamine - grams &er day for t%e last year) Last fall+

after de'elo&ing diarr%ea and &ain+ s%e was &laced on &rednisone 0. mg daily) S%e %ad acom&lete remission and+ after a "$mont% ta&ering of t%e &rednisone+ suffered a rela&se)

Prednisone was restarted C mont%s ago at 0. mg daily+ and now as t%e dose %as decreased to C.

mg &er day+ t%e diarr%ea %as recurred) S%e is %a'ing 0 to water stools &er day+ cram&y &ain+

and some weig%t loss) 9%at would be t%e best next ste&

;!< Restart t%e &rednisone and &lan to maintain t%e dose at -.$0. mg indefinitely

;B< Restart t%e &rednisone wit% 0$merca&to&urine and &lan on &rednisone ta&er in C mont%s

;4< Sto& t%e &rednisone and add cyclos&orine

;D< !dmit to t%e %os&ital and gi'e %ig%$dose intra'enous steroids to induce remission

;E< Sto& t%e mesalamine and add met%otrexate

!nswer:

;B< Restart t%e &rednisone wit% 0$merca&to&urine and &lan on &rednisone ta&er in C mont%s

Ex&lanation:

Prednisone is effecti'e in treating acti'e 4ro%n=s disease for s%ort durations ;"$0 mont%sat%io&rine are steroid$s&aring medications used to limit

t%e need for &rednisone) Prednisone+ li(e ot%er corticosteroids+ %as numerous side effects and s%ould only be

used for treating acti'e flares of disease+ not maintenance of remission) 4yclos&orine and met%otrexate %a'elimited roles in t%e management of 4ro%n=s disease)


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astroenterology

Record "

! 0?$year$old man &resents to t%e emergency room wit% com&laints of wea(ness+ generali>ed

swelling in %is extremities+ and rig%t leg &ain) !t t%e time of &resentation+ %e a&&ears to be in

moderate distress from t%e leg &ain) 8%e &atient states t%at %is sym&toms started two days ago)

8%e &atient also %as freAuent urination and increased t%irst) *e states t%at %e %as felt wea( fort%e &ast few mont%s) P%ysical examination re'eals a tender+ eryt%ematous+ and swollen rig%t

calf) *e also %as C &itting edema in all extremities) Blood &ressure is 1.F/?? mm *g+ and

tem&erature is 1..)" G) 5enous ultrasound is &ositi'e for lower extremity dee& 'ein t%rombosis)

Laboratory studies re'eal:

9%ite cell count 11+.../mm"H %ematocrit "C)"2H &latelets 1.?+.../mm"H K -). mEA/LH BI7

C- mg/dLH creatinine 1)F mg/dL) 8%e P8/P88 are normal)

8otal bilirubin .)- mg/dL+ !S8 C I/L+ albumin l)# g/dL+ c%olesterol "C0 mg/dLH triglycerides

-C? mg/dL)

Irine di&stic( s%ows &rotein "+ %emoglobin 1+ w%ite cells 1H C-$%our urine s%ows 0)C grams

of &rotein)

9%at is t%e next ste& in t%e treatment of t%is &atient

;!< Renal bio&sy

;B< Plasma&%eresis

;4< !nticoagulation;D< 4yclo&%os&%amide

;E< Prednisone

!nswer:

;4< !nticoagulation

Ex&lanation:

8%is &atient %as ne&%rotic syndrome based on t%e &resence of edema+ %y&er&roteinuria+ %y&o&roteinemia+ and

%y&erli&idemia) Suc% &atients are &redis&osed to de'elo&ing a %y&ercoagulable state secondary to t%e renallosses of &roteins 4 and S and antit%rombin @@@+ as well as increased &latelet acti'ation) Patients wit% e'idence

of 'enous t%rombosis s%ould be anticoagulated for at least 0 mont%s) Recurrent t%rombosis and renal 'eint%rombosis warrant lifelong anticoagulation)

!lt%oug% %e may need a renal bio&sy+ %e needs to %a'e %is t%rombus treated first as t%e JnextJ ste&) 8%e same is

true of using cyclo&%os&%amide and &rednisone) 8%is &atient most li(ely %as membranous glomerulone&%ritissim&ly because %e is an adult wit% ne&%rotic syndrome+ and t%is is t%e most common cause in adults)

4olonosco&y s%ould also be done in a &atient li(e t%is because t%ere is a strong association of

glomerulone&%ritis wit% solid tumors+ suc% as colon and breast cancer)


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7e&%rology

Record -

! -C$year$old man from 5ietnam+ w%o %ad been a bus dri'er in 8%ailand+ &resents to t%e emergency de&artment

after %a'ing s%ortness of breat% w%ile &laying soccer wit% %is son t%is morning) ,'er t%e last se'eral mont%s+ %e

%as been %a'ing se'eral e&isodes of s%ortness of breat%) Se'eral of t%e e&isodes were associated wit% c%est &ain

*e denies any significant medical %istory) *e %as a C?$&ac($year use of tobacco+ and %e %as a sedentarylifestyle) *is fat%er %ad a myocardial infarction at t%e age of ?#) *is %eart rate is FC/min+ blood &ressure is

1-./00 mm *g+ and res&iratory rate is 1-/min) *is examination s%ows mild ugulo'enous distention wit% a

colla&sing carotid arterial &ulse) *is cardiac examination re'eals a &oint of maximal im&ulse t%at is dis&lacedlaterally and inferiorly and a mild diastolic blowing murmur at t%e base w%ile %e sits u&) *is sensory

examination s%ows loss of 'ibration sense in all extremities+ and an abnormal Romberg test) EK s%ows normal

sinus r%yt%m wit% left axis de'iation and S8$segment de&ression and 8$wa'e in'ersion in leads @+ a5L+ 5?+ and50) 8%e c%est x$ray s%ows an enlarged %eart wit% dilatation of t%e &roximal aorta) 8%e 4B4+ c%emistries+ and

cardiac en>ymes are negati'e) 8%e ec%ocardiogram s%ows an eection fraction of 0.2) 9%at is t%e next best

ste& in t%e management of t%is &atient;!< 8reat wit% digitalis

;B< Exercise stress test;4< 4ardiac cat%eteri>ation

;D< 5DRL and lumbar &uncture+ followed by &enicillin t%era&y;E< !ortic 'al'e re&lacement

!nswer:

;D< 5DRL and lumbar &uncture+ followed by &enicillin t%era&y

Ex&lanation:

8%is &atient %as a murmur of aortic regurgitation ;!R< and an abnormal neurological examination+ suggestingsy&%ilis) 8%erefore+ t%is &atient needs a 5DRL and a lumbar &uncture) Sy&%ilis of t%e aorta in'ol'es t%e intima

of t%e coronary arteries and may narrow t%e coronary ostia+ leading to myocardial isc%emia) 8%ere is also

destruction of t%e medial muscle layers of t%e aorta+ leading to aortic dilation) 3yocardial isc%emia in !R

%a&&ens because oxygen reAuirements are ele'ated secondary to left 'entricular ;L5< dilatation and ele'ated L5systolic wall tension) 4oronary blood flow is normally during diastole w%en t%e diastolic arterial &ressure is

subnormal) 8%is leads to decreased coronary &erfusion &ressure)

7ifedi&ine or !4E in%ibitors are only used once t%e &atient de'elo&s se'ere !R) Digoxin is of 'ery limited use

at any time) !n exercise stress test is not indicated because of t%e baseline EK abnormalities) ou normally

detect t%e &resence of isc%emia on a stress test by loo(ing for t%e de'elo&ment of S8$segment de&ression) 8%is

&atient already %as baseline S8$segment de&ression) ! t%allium or sestamibi scan would be reAuired in a caseli(e t%is) @f you were in'estigating for isc%emia+ surgical treatment does not restore normal L5 function) Patients

wit% !R and normal L5 function are followed until surgery is indicated) 8%is is w%en t%e &atient %as L5

dysfunction but before t%e de'elo&ment of sym&tomatic congesti'e failure) 5al'e re&lacement is also indicatedin asym&tomatic &atients w%en t%e eection fraction falls to M??2 or L5 end$diastolic 'olume is N?? mL/mC)

!lt%oug% cat%eteri>ation may be useful before surgery+ it would not be done before a s&ecific diagnosis of

sy&%ilitic aortitis %as been confirmed and treatment wit% &enicillin %as been gi'en)


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4ardiology

Record ?

! -.$year$old woman is broug%t to t%e emergency de&artment by %er daug%ter w%o states t%at s%e found %er

mot%er at %ome se'eral %ours ago+ confused+ let%argic+ and unable to get u& from %er c%air or s&ea() *er mot%er

%as a sei>ure disorder for w%ic% ta(es an antisei>ure medication) S%e also %as a %istory of alco%ol abuse in t%e

remote &ast) Gor t%e &ast se'eral wee(s+ %er mot%er %as been com&laining of difficulty slee&ing and anxiety) 8%e &atient is stu&orous and unres&onsi'e to 'erbal stimuli) *er blood &ressure is 1../0. mm *g+ %eart rate is

?./min+ and res&iratory rate is #/min) 8%e &u&ils are &in&oint+ and t%ere is %ori>ontal nystagmus) !sterixis is

&resent)

Laboratory examinations re'eal: w%ite cell count #+../mm"+ sodium 1?. mEA/L+ BI7 1 mg/dL+ creatinine

.)# mg/dL+ glucose ?. mg/dL+ calcium ? mg/dL+ ammonia 1.. 6g/dL+ albumin "). g/dL+ !S8 1.. I/L+ !L8 .I/L) 8%e urinalysis and lumbar &uncture are normal) ! 48 scan of t%e brain s%ows cerebral edema) !rterial

blood gas s%ows a &* of F)C.+ a &4,C of -0 mm *g+ and a &,C of F# mm *g) ,smolar ga& is >ero) 8%e

toxicology screen is negati'e for ben>odia>e&ines and o&ioids) 9%at is t%e most li(ely substance t%at t%is &atient o'erdosed on

;!< P%enytoin

;B< 4arbama>e&ine;4< 5al&roic acid

;D< Et%anol

;E< 5alium

!nswer:

;4< 5al&roic acid

Ex&lanation:

8%is &atient most li(ely is intoxicated wit% 'al&roic acid) 8%is drug is widely used in t%e management of sei>ure

and mood disorders) 5al&roic$acid intoxication &roduces a uniAue syndrome consisting of %y&ernatremia+

metabolic acidosis+ %y&ocalcemia+ ele'ated serum ammonia+ and mild li'er aminotransferase ele'ation)*y&oglycemia may occur as a result of %e&atic metabolic dysfunction) 4oma wit% small &u&ils may be seen+

and t%is can mimic o&ioid &oisoning) Ence&%alo&at%y and cerebral edema can occur)

P%enytoin and carbama>e&ine are also commonly used antisei>ure medications) P%enytoin intoxication can

occur wit% only slig%tly increased doses) 8%e o'erdose syndrome is usually mild) 8%e most common

manifestations are ataxia+ nystagmus+ and drowsiness) *e&atic ence&%alo&at%y would be unusual)

4%oreoat%etoid mo'ements are occasionally seen) 4arbama>e&ine is a first$line agent for tem&oral lobee&ile&sy+ as well as trigeminal neuralgia) @ntoxication causes drowsiness+ stu&or+ coma+ or sei>ures) *owe'er+

dilated &u&ils and tac%ycardia are more common)

Signs of et%anol intoxication are similar to t%e signs of anticon'ulsant medication) @n addition+ it causes a %ig%

osmolar ga&) 5alium is an unli(ely cause of intoxication because t%is &atient=s blood ben>odia>e&ine le'els are

negati'e)


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Poisoning

Record 0

! ?C$year$old woman &resents to t%e emergency de&artment wit% fe'er+ wea(ness+ and abdominal &ain for t%e &ast t%ree days) @t %as been associated wit% nausea and t%ree e&isodes of 'omiting) *er %usband states t%at %er

tem&eratures %a'e been as %ig% as 1.")? G and t%at s%e %as not been %erself lately+ a&&earing confused and

let%argic) S%e %as a %istory of %y&ot%yroidism and migraine %eadac%es) S%e a&&ears let%argic+ de%ydrated+ and

is oriented only to &erson) *er blood &ressure is F?/?. mm *g+ tem&erature is 1.C)# G+ and &ulse is 1./min)S%e %as dry oral mucosa and %y&er&igmented areas of %er s(in s&read diffusely o'er t%e &osterior nec(+ %ands+

and (nuc(les) Rales are %eard o'er t%e rig%t lower lung field+ and t%e c%est x$ray s%ows a rig%t lower lobe

infiltrate) 8%e EK is normal) 8%e &atient is &laced on intra'enous %ydration) Laboratory studies s%ow a w%itecell count of 0+"../mm"+ and t%e differential s%ows C2 neutro&%ils+ F2 lym&%ocytes+ and #2 eosino&%ils)

8%e sodium le'el is 11C mEA/L+ wit% a &otassium of ?)# mEA/L and a c%loride of #C mEA/L) Bicarbonate le'el

is C. mg/dL+ and BI7 is "C mg/dL) 8%e creatinine le'el is normal) 8%e glucose le'el is 0. mg/dL+ and t%eurinalysis is normal) 9%at is t%e best initial test to diagnose t%is disorder

;!< @mmediate cortisol and assess !48* le'el;B< 3etyra&one stimulation test

;4< Early morning cortisol;D< ! cosyntro&in stimulation test

;E< C-$%our urine cortisol

!nswer:

;!< @mmediate cortisol and assess !48* le'el

Ex&lanation:

@n t%e context of acute adrenal crisis+ t%e most a&&ro&riate initial diagnostic test is to obtain a random cortisol

le'el before initiating treatment wit% intra'enous %ydrocortisone) @n a &atient w%o is %y&otensi'e and%emodynamically unstable+ it is ina&&ro&riate to &erform any diagnostic maneu'ers t%at reAuire se'eral ste&s to

obtain a diagnosis) ;8%e metyra&one stimulation and t%e cosyntro&in stimulation are suc% tests)< 8%e early$

morning cortisol is diagnostically useful if it is 'ery low+ w%ic% confirms adrenal insufficiency+ or 'ery %ig%+

w%ic% excludes adrenal insufficiency) ! C-$%our urine for cortisol is a test used to confirm t%e diagnosis of t%e%y&ersecretion of cortisol+ also (nown as 4us%ing=s syndrome+ w%ic% is t%e o&&osite of adrenal insufficiency)


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Endocrinology

Record F

! -?$year$old woman &resents to your office after de'elo&ing a &ruritic ras% and a fe'er) S%e first noticed it on

%er wrists two wee(s ago but states t%at it %as now s&read to %er feet as well) *er &ast medical %istory is

significant for a sei>ure disorder following t%e remo'al of a meningioma) S%e %as been treated wit% Dilantin)

P%ysical examination is significant for icteric sclera) 8%ere are &olygonal+ flat$to&&ed+ 'iolaceous &a&uleslimited to %er wrists and %er an(les) ! w%ite+ reticulated+ lacy lesion is also e'ident on examination of %er

buccal mucosa) *er li'er is enlarged and is nontender to &al&ation) Laboratory analysis re'eals: P8 11 seconds+

albumin ")0 g/dL+ al(aline &%os&%atase 10. I/L+ !S8 F.. I/L+ !L8 #0. I/L+ !7! 1:10.) !nti$%e&atitis 4'irus ;second generation< is negati'eH anti$%e&atitis$B surface antibody ;*Bs< is &ositi'eH and anti$%e&atitis$B

core antibody ;*bc


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astroenterology

Record

! C$year$old female comes to t%e emergency de&artment wit% a %eadac%e and fe'er) S%e %as not %ad anyrecent infections+ nor %as s%e been ex&osed to any drugs) *er medical %istory is unremar(able) ,n examination+

t%e &atient a&&ears let%argic) *er tem&erature is 1..)? G+ &ulse is 1../minute+ blood &ressure is 1"./? mm *g+

and res&irations are 1/min) *er conuncti'ae are yellowis%+ and scattered &etec%iae are noted on t%e lower

extremities) 8%e li'er and s&leen are not enlarged)

Laboratory studies s%ow t%e following results: 9B4 1C+.../mm"H %ematocrit CF2H &latelets 1-+.../mm"H

bilirubin -)? mg/dLH direct bilirubin .)? mg/dLH BI7 -. mg/dLH creatinine ")? mg/dL) P8+ fibrinogen+ and P88are all normal) *er &eri&%eral blood smear s%ows fragmented red blood cells)

9%at is t%e most effecti'e treatment for t%is &atient

;!< S&lenectomy

;B< lucocorticoids;4< Plasma&%eresis

;D< @ntra'enous immunoglobulins;E< Platelet transfusion

!nswer:

;4< Plasma&%eresis

Ex&lanation:

8%is woman %as a combination of %emolytic anemia wit% fragmented RB4s on &eri&%eral smearH

t%rombocyto&eniaH fe'erH neurologic sym&tomsH and renal dysfunction $$ a classic &entad of sym&toms t%at

c%aracteri>es t%rombotic t%rombocyto&enic &ur&ura ;88Pen &lasma) 8reatment s%ould be continued daily until t%e

&atient is in com&lete remission) Platelet transfusions in &atients wit% 88P are contraindicated and can be

associated wit% acute clinical deterioration) !nti&latelet agents+ s&lenectomy+ intra'enous immunoglobulin+ andimmunosu&&ressi'e agents %a'e not been of reliable benefit to &atients wit% 88P) Eac% is less effecti'e t%an

&lasma&%eresis) lucocorticoids are useful in &atients if &lasma&%eresis does not wor()


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*emotology$,ncology

Record #

! ?$year$old woman comes to your office) S%e is currently in atrial fibrillation and is asym&tomatic) *er rateis F./min) S%e denies %y&ertension+ diabetes+ and congesti'e failure) 8%ere is no ot%er &ast medical %istory)

9%at is t%e most a&&ro&riate management of t%is &atient

;!< 9arfarin and clo&idogrel;B< *e&arin followed by warfarin

;4< Low$molecular$weig%t %e&arin

;D< !s&irin ;"C? mg< daily;E< 9arfarin to maintain an @7R of C to "

!nswer:

;D< !s&irin ;"C? mg< daily

Ex&lanation:

8%is is a young &atient w%o %as an e&isode of atrial fibrillation in t%e absence of ot%er &reexisting conditions)

8%e !merican 4ollege of 4%est P%ysicians %as establis%ed guidelines for anticoagulation in nonr%eumatic atrialfibrillation) Patients wit% ris( factors for t%e formation of t%rombi suc% as a &re'ious stro(e+ transient isc%emic

attac(+ systemic t%romboembolism+ left 'entricular dysfunction+ recent congesti'e %eart failure+ systemic

%y&ertension+ or diabetes s%ould be &laced on warfarin to an @7R of C to ") Patients wit% no ris( factors w%o areyounger t%an 0? years are considered to be low ris( and s%ould ta(e one as&irin daily) !s&irin is also suitable

for &atients wit% a contraindication to warfarin t%era&y) 8%e efficacy of ot%er anti&latelet agents %as not been

&ro'en in &atients wit% atrial fibrillation)


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4ardiology

Record 1.

! 0C$year$old man &resents to your clinic com&laining of four days of dysuria+ freAuency+ and urgency) *e feels

slig%tly fe'eris% and %as %ad dull+ lower$bac( &ain for t%e &ast few mont%s) *e %as %ad se'eral e&isodes of t%e

dysuria o'er t%e last se'eral mont%s) Eac% time %e was gi'en antibiotics for one wee(+ and t%e sym&toms

resol'ed) 4urrently %is tem&erature is 1..)- G) 8%e genital examination is unremar(able+ and t%e digital rectalexamination re'eals a nontender &rostate+ w%ic% is normal in si>e and consistency+ wit% no &al&able masses)

!fter gentle massage of t%e &rostate+ a small amount of &urulent disc%arge is extruded from t%e uret%ral meatus)

8%e urine culture grows 1..+... colonies/mL of E) coli) Irine cultures from %is &rior sym&tomatic e&isodesalso grew E) coli but only 1.+... colonies/mL) 9%ic% of t%e following is most a&&ro&riate

;!< 4ystosco&y;B< 4i&rofloxacin and a>it%romycin orally once now

;4< 8rimet%o&rim/sulfamet%oxa>ole for one wee(

;D< Renal ultrasound;E< 4i&rofloxacin for - to 0 wee(s

!nswer:

;E< 4i&rofloxacin for - to 0 wee(s

Ex&lanation:

8%is &atient %as c%ronic bacterial &rostatitis) 4%ronic &rostatitis can &resent wit% lower abdominal &ain+ &erineal

&ain+ or low bac( &ain) 8%ere is usually no dysuria unless t%ere is accom&anying cystitis) ,n &%ysicalexamination+ t%e &rostate usually feels normal and is nontender) !s in t%is &atient+ c%ronic &rostatitis may

manifest as a recurrent urinary tract infection ;I8@


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4ardiology

Record 1C

! "F$year$old+ *@5$&ositi'e man comes for e'aluation of generali>ed wea(ness+ diffuse muscle &ain+ and

freAuent %eadac%es t%at began eig%t wee(s after t%e start of new *@5 medications) *e %as ne'er %ad any

sym&toms from %is *@5 infection+ and %e %as a 4D- of C??/6L and an *@5 R7! 'iral load of C?+... ;by P4Rido'udine+ lami'udine+ and ritona'ir/lo&ina'ir) *is &ast medical %istory issignificant for %y&ertension and %y&erc%olesterolemia) *is medications include sim'astatin and meto&rolol) *is

&%ysical examination is significant for diffuse muscle tenderness of t%e extremities) 8%e range of motion is

decreased because of &ain wit% mo'ement) *is &otassium le'el is ?)- mEA/L+ serum bicarbonate is 10 mEA/L+BI7 is "? mg/dL+ creatinine is 1)0 mg/dL+ and %is 'iral load is R7! -.+...) 8%e genoty&ing test result is

&ending) 9%at will you do w%ile waiting for t%is result

;!< Switc% >ido'udine and lami'udine to didanosine and sta'udine+ and continue ritona'ir

;B< Switc% >ido'udine+ lami'udine+ and ritona'ir/lo&ina'ir to didanosine+ sta'udine+ and indina'ir+ and sto&

sim'astatin;4< 4ontinue all medications but sto& sim'astatin

;D< 4ontinue >ido'udine and lami'udine+ and switc% ritona'ir/lo&ina'ir to efa'iren>;E< Switc% to didanosine+ sta'udine+ and efa'iren>+ and sto& sim'astatin

!nswer:

;E< Switc% to didanosine+ sta'udine+ and efa'iren>+ and sto& sim'astatin

Ex&lanation:

8%is &atient &resents wit% a drug interaction between t%e &rotease in%ibitors and t%e *3$4o! reductase

in%ibitor) @n t%is case+ it is wit% ritona'ir and sim'astatin) 8%is can &roduce significant toxicity from t%e statin)

Ritona'ir can increase t%e serum concentration of sim'astatin+ causing se'ere myalgias+ r%abdomyolysis+ and &otential renal insufficiency) 8%e next necessary ste& is to sto& sim'astatin or c%ange t%e &rotease in%ibitor to a

non$nucleoside re'erse$transcri&tase in%ibitor+ suc% as efa'iren>) *owe'er+ in t%is case+ t%e &atient also &resents

wit% failure to ac%ie'e a reduction in *@5 'iral load of 1 log after eig%t wee(s of t%era&y) @n t%e e'ent of

inadeAuate treatment of *@5 infection+ t%e best c%oice would be to start two new nucleoside re'erse$transcri&tase in%ibitors ;7R8@s< and use efa'iren> instead of ritona'ir+ in addition to discontinuing t%e

sim'astatin) @t is not enoug% to c%ange ritona'ir to indina'ir because %ig%$le'el cross$resistance is 'ery li(ely)

enoty&ing guides t%e t%era&eutic c%oice of all treatment failures) 8%e best t%ing to do w%en treatment isinsufficient is to use as least two+ and &referably t%ree+ new drugs)


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@nfectious Diseases

Record 1"

! ??$year$old man &resents wit% abdominal &ain and diarr%ea for t%e &ast " mont%s) *e %as also noticed a

weig%t loss of 1. lb during t%is &eriod) *e denies nausea+ 'omiting+ melena+ or %ematoc%e>ia) *e consumes fi'e

to six beers eac% wee(end+ smo(es %alf a &ac( of cigarettes a day+ but %as ne'er used intra'enous drugs) 8%e

&ast medical %istory is significant for osteoart%ritis+ newly diagnosed diabetes on a trial diet for C mont%s+ andrecurrent duodenal ulcers found on four se&arate u&&er endosco&ies) *e ta(es diclofenac/miso&rostol and

famotidine -. mg bid) 8%ree years ago+ %e %ad ta(en tri&le antibiotics to treat *) &ylori) *e also tells you t%at

tumors run in %is family) *is 'ital signs are normal) P%ysical examination is significant for mild e&igastrictenderness to dee& &al&ation wit%out radiation) Routine labs ordered s%ow: 9B4 +?../mm"+ %emoglobin 1")-

g/dL+ %ematocrit -.)12+ &latelets C?0+.../mm"+ amylase 1?? I/L+ sodium 1-1 mEA/L+ &otassium -)C mEA/L+

c%loride 1.0 mEA/L+ 4,C C" mm *g+ BI7 1? mg/dL+ creatinine 1). mg/dL+ glucose 1 mg/dL+ and calcium11)C mg/dL ;ele'atedyme studies

!nswer:

;D< Gasting serum gastrin le'el

Ex&lanation:

8%is &atient=s %istory of Jtumors in t%e familyJ is consistent wit% 3E7$1 ;%y&er&arat%yroidism+ gastrinomas+

and &ituitary tumors


14/160

astroenterology

Record 1-

! slim+ %ealt%y ".$year$old woman is sc%eduled for a dental &rost%odontic &rocedure and was sent for medical

e'aluation of a (nown %istory of mitral 'al'e &rola&se ;35Pe of t%e left 'entricle and mitral 'al'e+ t%ere isune'en closure of t%e 'al'e during eac% %eartbeat and subseAuent &rola&se of t%e leaflets into t%e left atrium)

8%e &rola&se is similar to t%e o&ening of a &arac%ute) 8%e &rola&se causes t%e classic mid$to$late systolic clic()

@f t%ere is regurgitation of blood bac( into t%e atrium+ an a&ical systolic murmur can often be a&&reciated u&on

auscultation)

8%is &atient is generally %ealt%y and %as a (nown %istory of 35P) ,n examination+ s%e is found to %a'e t%e

midsystolic clic( but no systolic murmur) 8%e lac( of a murmur indicates t%at blood is not being regurgitatedinto t%e atrium) @n t%is setting+ t%e &atient does not reAuire antibiotics for endocarditis &ro&%ylaxis &rior to t%e

dental &rocedure) Pro&%ylaxis for &atients wit% 35P is recommended if a murmur is &resent or if e'idence of

nontri'ial mitral regurgitation is found on t%e ec%ocardiogram) Because t%e &atient %as a (nown %istory of

35P+ s%e would not reAuire a cardiology consultation or ec%ocardiogram to reconfirm t%e diagnosis) @n fact+ anec%ocardiogram is not a reAuired study to diagnose 35P because dynamic auscultation can be more reliable)

Gurt%ermore+ t%e fact t%at s%e %as remained sym&tom$ and com&laint$free would indicate t%at %er condition is

stable+ and so no study s%ould be warranted at t%is time) Besides all t%is+ dental &rost%odontic &rocedures do notneed antibiotic &ro&%ylaxis)


15/160

4ardiology

Record 1?

! -.$year$old man comes to t%e office because of &ain in %is rig%t (nee for t%e &ast t%ree days) 8%e &atientdenies fe'er+ 'omiting+ or dysuria) *e %as no %istory of trauma but admits to &rior e&isodes of &ain+ es&ecially

after binge drin(ing) @t usually occurs in t%e (nee+ an(le+ or big toe and is relie'ed somew%at by ibu&rofen) *e

ta(es no medications and %as no allergies) *e %as a C?$&ac($year smo(ing %istory and drin(s about %alf a case

of beer w%en %anging out wit% friends) *is mot%er de'elo&ed t%e same sym&toms at t%e age of ?.) ,nexamination+ t%e rig%t (nee a&&ears swollen+ red+ and tender to &al&ation and %as a limited range of motion) ou

decide to as&irate t%e (nee oint) 9%ic% of t%e following is most consistent wit% %is diagnosis

;!< Positi'ely birefringent+ r%omboid$s%a&ed crystals and C.. w%ite cells/6L

;B< Bi&yramidal crystals and C+... w%ite cells/mL

;4< 7egati'ely birefringent+ r%omboid$s%a&ed crystals and C.+... w%ite cells/6L;D< 4loudy and watery fluid wit% wea(ly &ositi'e birefringent crystals and C.+... w%ite cells/6L

;E< 9atery fluid wit% strongly negati'e birefringent crystals and C.+... w%ite cells/6L

!nswer:

;E< 9atery fluid wit% strongly negati'e birefringent crystals and C.+... w%ite cells/6L

Ex&lanation:

out is a metabolic disease t%at most often occurs in men at middle age or older) @t rarely occurs in women untilt%ey are &ostmeno&ausal) 8%e acute gouty e&isode ty&ically %a&&ens at nig%t and is broug%t on by excessi'e

alco%ol use+ trauma+ surgery+ dietary excess+ or glucocorticoid wit%drawal) 8%e oint fluid as&irate a&&ears

cloudy because of t%e numerous w%ite cells) 8%ey ty&ically range in number from ?+... to ?.+.../6L) 8%e cellcount in t%is range can be found in any (ind of inflammatory art%ritis+ suc% as gout+ &seudogout+ or r%eumatoid

art%ritis) 4rystal analysis is reAuired to distinguis% t%em) out will %a'e negati'ely birefringent+ needle$s%a&ed

crystals+ w%ereas &seudogout will %a'e wea(ly &ositi'e+ r%omboid$s%a&ed crystals) R%eumatoid art%ritis s%ould%a'e no crystals) Se&tic art%ritis from infection usually gi'es N?.+.../6L w%ite cells in t%e syno'ial fluid) 8%e

inflammatory &rocess causes brea(down of %yaluronate in t%e oint fluid and ma(es it become watery)


16/160

R%eumatology

Record 10

! "?$year$old man comes to t%e %os&ital after an e&isode of synco&e) 8%ere were no &receding sym&toms+ andt%e &atient reco'ered ra&idly and com&letely wit% no residual effects) 8%e &atient did not %a'e sei>ure acti'ity

during t%e e&isode) 8%ere is no %istory of %eart disease and no &re'ious e&isodes of synco&e) 8%e &atient li'es in

rural 4onnecticut) *is only &re'ious medical &roblem was bilateral facial &alsy se'eral mont%s ago) 4urrently+

t%e &%ysical examination is normal+ exce&t for a %eart rate of ?C/min) *is blood &ressure is normal) !n EKs%ows a sinus r%yt%m wit% 3obit> @@ second$degree %eart bloc( wit% a PR inter'al of .)"- seconds)

Ec%ocardiogram is normal) *e %as a &ositi'e 5DRL and a negati'e G8!) 9%at is t%e most a&&ro&riate

management of t%is &atient

;!< Doxycycline in addition to electro&%ysiological studies

;B< 4eftriaxone in addition to &acema(er ;4< 4eftriaxone in addition to &rednisone

;D< 4eftriaxone

;E< Doxycycline in addition to &ermanent &acema(er

!nswer:

;B< 4eftriaxone in addition to &acema(er

Ex&lanation:

8%is &atient seems to %a'e second$degree %eart bloc( secondary to Lyme disease) *e li'es in 4onnecticut+

w%ic% is an endemic area) ;8%e city of Lyme is in 4onnecticut)< Gacial &alsy is t%e most common neurological

manifestation of Lyme disease) 8%e false &ositi'e 5DRL is c%aracteristic as well) Besides+ t%e &atient is 'eryyoung and %as no ot%er reason to %a'e %eart bloc(+ suc% as isc%emic %eart disease) @n Lyme disease+ %ig%$grade

!5 bloc( wit% a PR inter'al of N.)" seconds is an indication for intra'enous t%era&y wit% eit%er ceftriaxone or

&enicillin) ! &acema(er s%ould be &laced at least tem&orarily in t%ose wit% a 3obit> @@ %eart bloc( because oft%e ris( of &rogressing on to t%ird$degree bloc() 8%is &atient is also se'erely sym&tomatic from %is %eart bloc(

and %as %ad synco&e) Prednisone was used in t%e &ast but is inferior to an antibiotic alone) Steroids would only

be used in t%ose for w%om t%e %eart bloc( does not im&ro'e wit% antibiotics) 3ore minor forms of Lyme

disease can treated wit% oral doxycycline) Doxycycline can be used wit% t%ose w%o %a'e ust t%e ras%+ ointsym&toms+ facial &alsy+ or first$degree %eart bloc()


17/160

4ardiology

Record 1F

! C1$year$old man wit% no significant &ast medical %istory &resents to office wit% com&laints of blood in %is

urine and mucosal bleeding w%ile brus%ing %is teet%) 8%e &atient com&lains of intermittent Jringing in t%e ears)J

*e denies any drug or alco%ol use) *e %as no family %istory of bleeding disorders) Petec%iae are noted in t%e

oral ca'ity+ as is dried blood in t%e nostrils)

Laboratory studies s%ow t%e following:

*ematocrit "C2H w%ite blood cell count +.../mm" wit% 0.2 neutro&%ilsH &latelet count 1"+...H P8 1"

secondsH P88 C secondsH LD* 1+C.. I/LH ele'ated indirect bilirubin)

4oombs= test is &ositi'eH abdominal examination is normalH and t%e &eri&%eral smear s%ows s&%erocytes)

9%at is t%e most li(ely diagnosis

;!< !l&ort=s syndrome;B< Bernard$Soulier syndrome

;4< Gelty=s syndrome;D< 8%rombotic t%rombocyto&enic &ur&ura

;E< E'ans= syndrome

;G< @dio&at%ic t%rombocyto&enic &ur&ura ;@8P<

!nswer:

;E< E'ans= syndrome

Ex&lanation:

E'ans= syndrome is t%e association of autoimmune %emolysis wit% autoimmune t%rombocyto&enia) @t is treated

initially wit% steroids and may occasionally need s&lenectomy to control t%e disease)

!l&ort=s syndrome is t%e congenital association of glomerulone&%ritis wit% sensorineural %earing loss and ocular

&roblems)

Bernard$Soulier syndrome is a functional &latelet disorder &resenting wit% &latelet$related bleeding wit% a

normal &latelet count)

Gelty=s syndrome is t%e association of r%eumatoid art%ritis wit% neutro&enia and s&lenomegaly) @t is occasionallyassociated wit% t%rombocyto&enia) 8%is &atient %as no %istory of r%eumatoid art%ritis+ and t%e s&leen and

neutro&%il count are normal)

@8P would not gi'e t%e e'idence of %emolysis t%at is &resent %ere+ suc% as an increased bilirubin+ &ositi'e

4oombs= test+ %ig% LD*+ or anemia) 8%is &atient does not %a'e t%e renal failure or fe'er associated wit% 88P) @n

addition+ 88P s%ould gi'e fragmented red cells on &eri&%eral smear)


18/160

*emotology$,ncology

Record 1

! "1$year$old woman &resents to t%e emergency de&artment wit% t%ree %ours of s%ortness of breat%) S%e %ad

been wal(ing %er dog t%is afternoon and %ad not been outside for more t%an a few minutes before s%e began to

feel c%est tig%tness+ w%ee>ing+ and a coug%) S%e %as not %ad any relief from %er bronc%odilators or steroid

in%alers t%at s%e uses daily) S%e states t%at %er daily acti'ities %a'e become affected by freAuent e&isodes ofs%ortness of breat% t%at recur a few times during eac% wee() 8%ese attac(s can last days at a time+ and s%e is

afraid t%at %er current medications are no longer of assistance to %er) ,n &%ysical examination+ s%e %as a

tem&erature of #) G+ a &ulse of #/min+ a blood &ressure of 1"0/#. mm *g+ and a res&iratory rate of C"/min)8%ere is some e'idence of %y&eremia and secretions in t%e nasal &assages bilaterally) S%e is using %er accessory

muscles to breat%e+ and w%ee>ing is audible) Pulmonary function testing re'eals an GE51 of 02 of &redicted+

wit% a reduced GE51/G54 ratio) 8%is increases by 1-2 after %ig%$dose bronc%odilators are administered) *er &ea( ex&iratory flow was 1? L/min before bronc%odilators were gi'en) !rterial blood gases on room air are:

&* F)"0+ &4,C - mm *g+ and &,C 0. mm *g) 4%est x$ray s%ows e'idence of %y&erinflated lungs) 8%e

se'erity of t%is &atient=s clinical condition corres&onds wit% w%ic% of t%e following classifications of ast%ma

;!< 3oderate intermittent;B< Se'ere intermittent

;4< 3ild &ersistent;D< 3oderate &ersistent

;E< Se'ere &ersistent

!nswer:

;D< 3oderate &ersistent

Ex&lanation:

8%is &atient &resents wit% an acute attac( of ast%ma+ li(ely &reci&itated by allergens from t%e en'ironment) *er

sym&toms are suggesti'e of moderate &ersistent ast%ma+ as s%e reAuires t%e daily use of an in%aled s%ort$acting

OC$agonist+ t%e exacerbations are affecting %er daily acti'ities+ and t%ey recur at a freAuency of more t%an twice

&er wee(+ lasting days at a time) ,t%er &arameters consistent wit% moderate &ersistent ast%ma are t%e occurrenceof nocturnal sym&toms more t%an once &er wee() *er GE51 'alue of 02 is consistent wit% t%e criteria for t%e

GE51 to fall between 0. and .2 of &redicted+ a reduced ratio of GE51/G54 to MF?2+ and t%e re'ersibility of

airflow obstruction wit% bronc%odilators of greater t%an 1C2) ! &ea( ex&iratory flow of less t%an C.. L/minindicates se'ere airflow obstruction) During a mild ast%ma exacerbation+ arterial blood gases may be normal or

re'eal a res&iratory al(alosis wit% an increased !$a gradient) 8%e combination of an increased Pa4,C and

res&iratory acidosis may indicate res&iratory failure+ and t%e need for mec%anical 'entilation s%ould be

considered)

8%ere are four classifications of ast%ma:

1) 3ild intermittent $$ sym&toms less t%an C/wee( and GE51 N.2C) 3ild &ersistent $$ sym&toms greater t%an C/wee( but less t%an l/day wit% GE51 N.2

") 3oderate &ersistent $$ daily sym&toms greater t%an C/wee( wit% GE51 N0. and M.2

-) Se'ere &ersistent $$ continual sym&toms wit% limited &%ysical acti'ity and GE51 M0.2


19/160

Pulmonary

Record 1#

9%at is t%e a&&ro&riate mode of colorectal cancer screening for t%e following case

! --$year$old man w%ose fat%er died of colon cancer at age FF and w%o is asym&tomatic)

;!< 4olonosco&y now and e'ery 1. years

;B< Glexible sigmoidosco&y now and e'ery ? years

;4< 4olonosco&y at age ?. and e'ery 1. years;D< 4olonosco&y now and e'ery 1. years

;E< Stool occult cards e'ery yearH colonosco&y if &ositi'e

;G< 4olonosco&y at age -. and e'ery ? years;< 4olonosco&y in " years

;*< 4olonosco&y in 1 year

;@< 4olonosco&y e'ery 1 to C years

!nswer:

;G< 4olonosco&y at age -. and e'ery ? years

Ex&lanation:

4olonosco&y is t%e &referred met%od of screening for colon cancer) !'erage$ris( &ersons s%ould undergo

colonosco&y at age ?.+ and if normal+ e'ery 1. years) @f a &oly& is found+ t%e colonosco&y s%ould be re&eated

after " years) 9%en t%ere is a family %istory of colon cancer+ screening s%ould begin at age -. or ten years &riorto t%e age of t%e family member) 8%e earlier date is res&ected) Gollow$u& examinations for &ersons wit% family

%istories of colon cancer s%ould occur at ?$year inter'als) 9%en t%ere are multi&le family members+ screening

colonosco&y s%ould be &erformed at age C? and e'ery 1 to C years ;c%aracteristic of &ersons wit% %ereditarynon&oly&osis colorectal cancer ;Lync% syndrome


20/160

astroenterology

Record C.

! 0#$year$old woman wit% a %istory of se'ere ast%ma is broug%t to t%e emergency de&artment by %er daug%ter

because of se'ere lig%t%eadedness) 8%e &atient also com&lains of worsening s%ortness of breat% and &rogressi'e

fatigue o'er t%e last year) Gor t%e last t%ree mont%s+ t%e &atient is able to wal( only C to " bloc(s before

de'elo&ing a &rofound s%ortness of breat%) S%e recently started using t%ree &illows for slee& during t%e nig%t)S%e denies c%est &ain and dia&%oresis) 8%e &atient=s daug%ter states t%at t%ree wee(s ago+ %er mot%er %ad a

synco&al e&isode t%at lasted for two minutes on %er way to t%e su&ermar(et) !t t%at time+ s%e did not see(

medical attention) 8%e &atient=s current medications include lisino&ril+ digoxin+ and furosemide)

@n t%e emergency room+ %er %eart rate is 1.C/min+ blood &ressure is 11?/F. mm *g+ and res&iratory rate is

CC/min) P%ysical examination re'eals ugulo'enous distension and bibasilar crac(les) *eart auscultationdemonstrates a diminis%ed S1+ a loud PC+ and an S" gallo&) 8%ere is a 1 &itting edema of bot% extremities)

EK s%ows normal sinus r%yt%m wit% se'eral multifocal &remature contractions ;P54s< and a four$beat run of

'entricular tac%ycardia ;58< at a rate of 1C/min) 8%e ec%ocardiogram re'eals an eection fraction below C?2and no e'idence of aortic stenosis) 8%e &atient is admitted to t%e telemetry unit+ and recordings s%ow P54s and

1C runs of nonsustained 58 of - to 1 beats in duration during t%e first day)

9%ic% of t%e following is t%e most a&&ro&riate management at t%is time

;!< @ncrease t%e dose of digoxin

;B< Start meto&rolol;4< Start amiodarone

;D< 4ardiac cat%eteri>ation

;E< Perform electro&%ysiologic study

!nswer:

;4< Start amiodarone

Ex&lanation:

8%is 0#$year$old woman wit% nonisc%emic cardiomyo&at%y %as &resynco&al and synco&al e&isodes most li(ely

caused by nonsustained 'entricular tac%ycardia) S%e is at a %ig% ris( for deat% from a cardiac arr%yt%mia and

s%ould be &laced on amiodarone+ w%ic% is effecti'e in reducing t%is ris() Beta$bloc(ers also can be beneficial inreducing t%e ris( of cardiac arr%yt%miasH %owe'er+ t%is &atient %as a %istory of se'ere ast%ma) 8%era&y wit%

beta$bloc(ers would not be t%e best c%oice) !lt%oug% intra'enous loading wit% amiodarone is not necessary at

t%is time+ oral loading is a&&ro&riate) 4ardiogenic synco&e can occur on a mec%anical or arr%yt%mic basis)

3ec%anical &roblems t%at can cause synco&e include aortic stenosis+ &ulmonary stenosis+ and %y&ertro&%icobstructi'e cardiomyo&at%y) E&isodes are commonly exertional or &ostexertional) 7eurological causes of

synco&e are far less common and less dangerous t%an are cardiac causes) @ncreasing t%e dose of digoxin will not

c%ange t%e ris( of de'elo&ing a 'entricular dyst%ymia) Electro&%ysiolocal studies s%ould be &erformed in &atients in w%om t%e synco&e seems to be of a cardiac etiology and a definite cause cannot be found) 8%is

&atient already %as 58 documented on t%e EK) Electro&%ysiological studies are also done to see if t%e &atient

needs an im&lantable defibrillator+ but t%is would not be t%e most a&&ro&riate next best ste&)


21/160

4ardiology

Record C1

! 0?$year$old man &resents to t%e emergency de&artment com&laining of &al&itations t%at started C. minutes

ago) *e states %e %ad a J%eart attac(J one year ago) *e smo(ed for twenty years and %as %ad diabetes for ten

years) *e watc%es %is diet and ta(es as&irin and ator'astatin) ,n &%ysical examination+ you find a %eart rate of

1-?/min+ a blood &ressure of 1-/? mm *g+ and a res&iratory rate of CC/min) *e %as intermittent wa'es in %is ugular 'eins consistent wit% canon JaJ wa'es+ and %is lungs are clear) 8%e S1 'aries in intensity) 8%e EK

s%ows t%at t%e QRS com&lex is a&&roximately .)10 seconds in duration+ wit% dissociation of t%e & wa'es from

t%e QRS com&lexes) !ll t%e QRS com&lexes are &ositi'ely deflected in all leads) *ow would you treat t%isgentleman

;!< 5era&amil;B< 4ardio'ersion

;4< !denosine

;D< @nsert a &acing cat%eter ;E< Procainamide

!nswer:

;E< Procainamide

Ex&lanation:

8%is &atient %as 'entricular tac%ycardia based on t%e &resence of a wide com&lex tac%ycardia and cannon JaJ

wa'es in t%e ugular 'eins) 4annon JaJ wa'es are due to t%e unsync%roni>ed contraction of t%e 'entricles andt%e atria) 8%is results in a retrograde flow of blood bac( to t%e ugular 'eins wit% atrial systole) 8%e 'ariation of

t%e intensity of S1 is caused by t%e 'entricle contracting at times w%en t%e !5 'al'es are o&en and at ot%er

times w%en t%ey are closed) Procainamide+ amiodarone+ and lidocaine are t%e most effecti'e treatments for a%emodynamically stable &atient)

5era&amil and adenosine can be dangerous in a &atient li(e t%is) 5era&amil is useful in su&ra'entricular

tac%ycardia ;S58


22/160

4ardiology

Record CC

! "0$year$old woman comes to your office claiming t%at s%e %as been feeling generali>ed wea(ness+ along wit%

stiff %ands+ wrists+ and (nees u&on awa(ening+ w%ic% lasts about C %ours) S%e %as also %ad a -$&ound weig%t

loss o'er t%e last C 1/C wee(s and an itc%y ras% on %er c%est) S%e claims t%e sym&toms began only C to " wee(s

ago+ and t%ey %a'e been debilitating) 8%e stiffness and &ain are bilateral and symmetrical) 8%e sym&toms %a'ecaused %er to be late to wor( and %a'e interfered wit% %er duties) S%e a&&ears tired) *er 'ital signs are normal)

8%ere is a maculo&a&ular+ fine ras% on %er anterior c%est wall+ w%ic% is not restricted to t%e s(in fold areas)

8%ere are no nodules) 8%e lungs+ %eart+ and abdomen are normal) *er extremities are not edematous+ but t%ere istenderness u&on &al&ation of wrists and (nees but no effusions or oint deformity) 8%ere is no tenderness o'er

t%e tendon s%eat%s) Laboratory studies s%ow: w%ite cell count +0../mm"+ %ematocrit "#)-2+ &latelets

C1?+.../mm"+ BI7 mg/dL+ creatinine .)# mg/dL+ glucose 1C? mg/dL+ and calcium )0 mEA/L) 8%er%eumatoid factor and !7! are negati'e) X$rays of t%e oints are normal) 9%ic% of t%e following is t%e most

a&&ro&riate action

;!< !nti$double$stranded D7!

;B< 4eftriaxone and doxycycline;4< 3et%otrexate

;D< @ntra'enous immunoglobulin ;@g<;E< Serum Par'o'irus B1# @g3

!nswer:

;E< Serum Par'o'irus B1# @g3

Ex&lanation:

8%is woman most li(ely %ad an acute infection wit% Par'o'irus B1#+ w%ic% can cause a syndrome t%at mimicsr%eumatoid art%ritis) !rt%ralgias from Par'o'irus B1# most commonly occur in woman in t%eir t%irties+ w%ereas

r%eumatoid art%ritis occurs more commonly in older indi'iduals) Par'o'irus B1# gi'es a &olyart%ritis t%at

affects t%e &roximal inter&%alangeal oints of t%e %ands+ wrists+ and (nees) !rt%ralgias are common) 8%e

diagnosis is mostly clinical w%en one gets a lacy+ maculo&a&ular+ truncal ras%+ along wit% malaise and a%eadac%e wit% little fe'er) 8%ere is a laboratory test for serum @g3 and @g for Par'o'irus B1#) 8reatment is

sym&tomatic+ and most of t%ese sym&toms will resol'e on t%eir own)

3et%otrexate is an incorrect c%oice because t%e &atient=s sym&toms are too new to be considered r%eumatoid

art%ritis+ w%ic% is usually at least 0 wee(s in duration and would be associated wit% a &ositi'e test for a

r%eumatoid factor in F?2 of &atients) 8%e !7! is also wea(ly and nons&ecifically &ositi'e in r%eumatoid

art%ritis) 8reatment for r%eumatoid art%ritis in'ol'es 7S!@Ds accom&anied wit% disease$modifying drugs+ suc%as %ydroxyc%loroAuine or sulfasala>ine) 8%ere may be a need for using t%ree agents in 'ery se'ere disease)

Some of t%e ot%er drugs t%at could be used are met%otrexate+ cyclos&orine+ and steroids)

@ntra'enous immunoglobulins are used to treat a&lastic crisis from &ar'o'irus) 8%is &atient=s %ematocrit is

normal) 8%e art%ralgias of &ar'o'irus s%ould resol'e wit%out s&ecific t%era&y+ and 7S!@Ds are only used for

sym&tomatic relief) 4eftriaxone and doxycycline would be used for gonococcal or c%lamydial art%ritis) @n t%atcase+ one would ex&ect fe'er+ migratory art%ritis+ a &etec%ial ras%+ and tenosyno'itis) 8esting for anti$double

stranded D7! would be a&&ro&riate for e'aluating a &atient for lu&us)


23/160

R%eumatology

Record C"

! ??$year$old woman comes to t%e clinic after being diagnosed wit% ty&e C diabetes mellitus during a routine

screening &erformed at wor() S%e is currently asym&tomatic and denies any %istory of freAuent urination) ,n

&%ysical examination+ you note a normal blood &ressure) *er %eart+ lungs+ and t%e remainder of t%e &%ysical

examination are wit%in normal limits) 9%en you as( t%e nurse to weig% your &atient+ you note %er body massindex ;B3@< to be "-) 9%at is t%e next ste& in t%e management of t%is &atient

;!< Begin intense insulin t%era&y;B< Begin gli&i>ide

;4< Begin &ioglita>one

;D< Begin acarbose;E< Begin metformin

!nswer:

;E< Begin metformin

Ex&lanation:

@n t%e obese &atient wit% new$onset+ ty&e$C diabetes mellitus+ t%e initial t%era&y of c%oice is metformin) ,f all

t%e oral %y&oglycemics+ metformin is t%e only medication t%at results in weig%t loss and a more fa'orable li&id &rofile) 3etformin wor(s &rimarily by su&&ression of %e&atic gluconeogenesis) !s a result+ t%is oral medication

will ne'er cause %y&oglycemia as a side effect)


24/160

Endocrinology

Record C-

! ?0$year$old man &resents to t%e emergency de&artment wit% com&laints of dys&nea on exertion for t%e last

t%ree days) 8%e &atient is normally able to wal( about eig%t bloc(s wit%out any &roblems+ but now can only

wal( one) *e doesn=t ta(e any medications and denies alco%ol and tobacco use) 5ital signs are: tem&erature #)F

G+ &ulse 1C0/min+ blood &ressure 1C-/0 mm *g+ and res&irations 1/min) 8%e ugulo'enous &ressure isele'ated+ and t%ere is a soft diastolic rumble at t%e a&ex wit% an o&ening sna&) Rales are &resent at bot% bases)

EK s%ows atrial fibrillation at a rate of 1C0/min) 9%at is t%e next best ste& in t%e management of t%is &atient

;!< Gurosemide

;B< Diltia>em

;4< 8ranseso&%ageal ec%ocardiogram;D< Start coumadin

;E< 3itral 'al'otomy

;G< Electrical cardio'ersion

!nswer:

;B< Diltia>em

Ex&lanation:

8%is &atient %as a diastolic murmur and an o&ening sna& consistent wit% mitral stenosis) !ll t%e t%era&ies

described may be useful in t%e management of mitral stenosis) !s is often t%e case on board tests+ all t%e

answers are &artially correct) 8%e initial ste& is to relie'e t%is &atient=s sym&toms by controlling t%e %eart rate)5entricular filling is im&aired by mitral stenosis) 8%e 'entricle fills during diastole) 8%e ra&id rate of atrial

fibrillation s%ortens diastolic filling time and causes t%e sym&toms) 8%e only t%era&y listed in t%e answer

c%oices t%at controls %eart rate is diltia>em) !lt%oug% furosemide will decom&ress t%e lungs+ it will not slow t%e%eart rate) !nd alt%oug% %e may e'entually need balloon 'al'otomy+ t%is would not be done before t%e %eart rate

%as been controlled) 4oumadin will e'entually be neededH worrying about a clot t%at mig%t form in a year is not

as im&ortant as controlling t%e sym&toms of dys&nea now) @t is unli(ely t%at anyt%ing found on an

ec%ocardiogram will ma(e you not control t%e rate) 8%e ec%ocardiogram is needed but will not c%ange t%e initialmanagement) Electrical cardio'ersion is not indicated for se'eral reasons) Girst+ %e is not acutely unstable) 8%e

dys&nea is on exertion+ not rig%t now) Second+ wit% mitral stenosis and w%at is surely an accom&anying left

atrial dilation+ %e will &robably re'ert bac( to atrial fibrillation) 8%e more abnormal t%e atrium is anatomically+t%e %arder it is to successfully cardio'ert) Ginally+ you would not want to cardio'ert atrial fibrillation in a &atient

wit% t%ree days of sym&toms wit%out eit%er a transeso&%ageal ec%o to exclude a clot or wit%out %a'ing gi'en

t%ree wee(s of anticoagulation &rior to t%e cardio'ersion)


25/160

4ardiology

Record C?

! ?1$year$old man is admitted to t%e %os&ital wit% t%e acute onset of %y&otension+ generali>ed wea(ness+ and

confusion) *e %as ex&erienced &rogressi'e s%ortness of breat% o'er t%e &ast two years+ w%ic% occurs now e'en

on minimal exertion) *e %as a %istory of multi&le transient isc%emic attac(s ;8@!s


26/160

Endocrinology

Record C0

! C$year$old woman &resents to your office com&laining of fatigue+ wea(ness+ anorexia+ art%ralgias+ and someoral ulcers t%at interfere wit% eating) S%e also %as been seen by a dermatologist for treatment of an eryt%ematous

ras% t%at gets worse wit% sun ex&osure) !ll of t%ese sym&toms %a'e been de'elo&ing slowly o'er t%e &ast

se'eral mont%s) *er &ast medical %istory is significant a &ositi'e PPD+ for w%ic% s%e %as been ta(ing isonia>id)

S%e also %ad 9olff$Par(inson$9%ite syndrome+ w%ic% is being treated wit% &rocainamide) S%e %as %ad two brief e&isodes of confusion o'er t%e &ast few mont%s t%at %ad resol'ed s&ontaneously) 8%ere is maculo&a&ular

ras% on t%e areas ex&osed to t%e sun) *er !7! is &ositi'e) 8%e %ematocrit is "")12+ &latelets are 11C+.../mm"+

BI7 is "C mg/dL+ and creatinine is C)C mg/dL) *er urinalysis s%ows C &rotein and some red cell casts) 9%at ist%e next best ste&

;!< !ntibody to single$stranded D7!;B< LE cell &re&aration

;4< !nti%istone antibodies

;D< Renal bio&sy;E< !ntimitoc%ondrial antibody

!nswer:

;D< Renal bio&sy

Ex&lanation:

!lt%oug% t%e &atient is on &rocainamide and isonia>id+ w%ic% can bot% gi'e a &ositi'e !7! and lu&us+ %er

clinical &resentation is not consistent wit% drug$induced lu&us) S%e %as 'ery clear renal in'ol'ement wit% &roteinuria and red cell casts in t%e urine+ as well as an ele'ated BI7 and creatinine) S%e also ex&erienced

some e&isodes of confusion+ w%ic% mig%t be lu&us cerebritis) 7eit%er central ner'ous system nor renal

in'ol'ement is found wit% drug$induced lu&us) S%e also %as %ematological disease+ w%ic% is rare wit% drug$induced lu&us) 8%e best way to confirm t%e diagnosis is wit% a renal bio&sy) !nti%istone antibodies+ LE cells+

and single$stranded D7! antibodies can be found in bot% s&ontaneous lu&us and drug$induced lu&us) @n

addition+ t%e renal bio&sy will greatly %el& in t%e c%oice of t%era&y because it tells us w%o needs

cyclo&%os&%amide or a>at%io&rine in addition to steroids for t%e management of diffuse &roliferati'e renaldisease) !ntimitoc%ondrial antibodies are seen wit% &rimary biliary cirr%osis+ not lu&us)


27/160

R%eumatology

Record CF

! CC$year$old man wit% a (nown family %istory of %y&ertro&%ic obstructi'e cardiomyo&at%y ;*,43< &resents

to t%e emergency de&artment wit% an e&isode of synco&e w%ile climbing t%e stairs to get to %is t%ird$floor

a&artment) *e was started on a beta$bloc(er twel'e mont%s ago but continued to %a'e sym&toms of dys&nea and

lig%t%eadedness) 5era&amil was added six mont%s ago+ but %e still %as %ad &ersistent sym&toms) 9%at would bet%e next best ste& in t%e management of t%is &atient

;!< 4ardiac trans&lantation;B< !4E in%ibitors

;4< Electro&%ysiology studies

;D< Surgical myomectomy;E< @nection of absolute alco%ol into t%e myocardium

!nswer:

;E< @nection of absolute alco%ol into t%e myocardium

Ex&lanation:

9%en beta$bloc(ers or negati'ely inotro&ic calcium bloc(ers suc% as 'era&amil are not effecti'e+ t%e &atient

will most li(ely need an anatomic re&air of %is %eart) !4E in%ibitors are not only useless but can actually bedangerous by increasing left 'entricular em&tying and increasing t%e outflow tract obstruction) 4ardiac

trans&lantation s%ould ne'er be tried before a sim&le attem&t at reducing t%e mass of t%e 'entricular se&tum is

made) !lt%oug% surgical myomectomy is t%e traditional &rocedure+ t%e se&tum can be reduced in si>e by using acat%eter to inect absolute alco%ol into t%e se&tal &erforator branc% of t%e left anterior descending artery to cause

small t%era&eutic infarctions t%at will reduce t%e si>e of t%e se&tum) !lt%oug% electro&%ysiological studies may

indicate t%e need for t%e &lacement of a dual c%amber &acema(er+ t%e &atient will still reAuire a mec%anicalreduction of t%e myocardium to relie'e w%at seems to be se'ere outflow tract obstruction)


28/160

4ardiology

Record C

! C?$year$old w%ite woman comes to your office today to meet you for t%e first time) *er only com&laint is of%eadac%es) *er blood &ressure is 10./1.? mm *g in bot% arms) S%e is obese and ot%erwise %as a normal

&%ysical examination wit% no bruits in %er abdomen) 8wo wee(s and t%ree wee(s later+ %er blood &ressure

remains ele'ated at 1??/1.F and 1?F/1.? mm *g+ res&ecti'ely) S%e smo(es but does not drin( alco%ol)

Laboratory studies s%ow:

Sodium 1" mEA/L+ &otassium -)F mEA/dL+ BI7 1- mg/dL+ creatinine .) mg/dL) Irinalysis re'eals 1

&rotein+ wit% no red or w%ite cells)

9%at is t%e next ste& to confirm a diagnosis

;!< Do&&ler ;du&lex< ultrasound of t%e (idneys

;B< Start lisino&ril

;4< 3agnetic resonance imaging ;3R@< of t%e abdomen;D< 4a&to&ril renogra&%y

;E< !ngiogra&%y

!nswer:

;D< 4a&to&ril renogra&%y

Ex&lanation:

8%is case illustrates a &atient wit% &ossible bilateral or unilateral renal artery stenosis ;R!S


29/160

7e&%rology

Record C#

! FC$year$old w%ite man is seen in t%e clinic wit% com&laints of increasing dys&nea on exertion and ort%o&nea)

8%e &atient recently mo'ed to t%e city and %as records of a recent %os&itali>ation four mont%s ago for dys&nea

u&on minimal acti'ity+ increasing fatigue+ and ort%o&nea) 8%e &atient %as a long$standing %istory of ast%ma and

diabetes) 3edications at t%is time include in%aled steroids+ in%aled beta$agonists+ and glyburide) !4E in%ibitorsand furosemide were started two mont%s ago)

5ital signs are: &ulse 1../min+ res&irations C-/min+ and blood &ressure 1?-/#- mm *g) 4ardio'ascularexamination re'eals a regular rate and r%yt%m+ and an S- is &resent) Bibasilar crac(les are e'ident in t%e c%est)

8%ere is no w%ee>ing) 8%ere is a trace bilateral &edal edema in t%e extremities+ and routine labs are normal+

exce&t for a BI7 of -C mg/dL and a creatinine of 1)# mg/dL) !n EK s%ows a sinus r%yt%m wit% left'entricular %y&ertro&%y) 4%est x$ray s%ows cardiomegaly and increased 'ascular congestion) Labs four mont%s

ago s%owed a BI7 of CF mg/dL and a creatinine of 1)C mg/dL) Ec%ocardiogram s%ows left 'entricular

%y&ertro&%y and an eection fraction of ?F2)

9%at is t%e next ste& in management in t%e management of t%is &atient

;!< @ncrease t%e dose of furosemide;B< Restrict salt and fluids and resc%edule a return a&&ointment in four wee(s

;4< @ncrease t%e dose of !4E in%ibitors

;D< !dd digoxin;E< Start t%e &atient on car'edilol

!nswer:

;E< Start t%e &atient on car'edilol

Ex&lanation:

8%is &atient %as congesti'e %eart failure ;4*G< due to diastolic dysfunction secondary to c%ronic %y&ertension+

wit% no mention of left 'entricular ;L5< systolic dysfunction) Diastolic dysfunction is more common in elderly+%y&ertensi'e &atients) Signs of &ulmonary or 'enous congestion in &atients wit% a L5 c%amber of normal si>e

indicate diastolic dysfunction) 8%e %y&ertro&%ic+ stiff left 'entricle needs more time to fill during diastole+ so

treatment wit% beta$bloc(ers %el&s in slowing t%e %eart rate and increasing cardiac out&ut) E'en t%oug% %e %asast%ma+ %is is not w%ee>ing now+ and so it would be best to decrease %is mortality wit% beta$bloc(ers) Diuretics

and nitrates s%ould be used wit% caution because t%e decrease in &reload may decrease cardiac out&ut and cause

%y&otension) 8%e use of increased diuretics is %el&ful in 'olume$o'erloaded &atients for relief of se'ere edema+

w%ic% is not &resent in t%is case) Reassurance+ dietary modification alone+ and resc%eduling a returna&&ointment is not an o&tion in t%is sym&tomatic &atient) !4E in%ibitors are more %el&ful in &atients wit% L5

systolic dysfunction and for lowering t%e systolic blood &ressure) 8%is &atient already %as &rerenal a>otemia+

and so it would be best to not sim&ly de&lete t%e intra'ascular 'olume e'en furt%er wit% more diuretics) Positi'einotro&ic agents li(e digoxin are effecti'e in &atients wit% 4*G secondary to systolic dysfunction) !lt%oug%

t%ey do not reduce mortality+ t%ese agents are effecti'e in reducing rates of %os&itali>ation and in im&ro'ing

sym&toms) 8%ey are also useful w%en worsening %eart failure is from atrial fibrillation wit% &oor rate control)


30/160

4ardiology

Record ".

! --$year$old man undergoes an u&&er endosco&y for c%ronic %eartburn) *e %as %ad no nausea+ 'omiting+

dys&%agia+ fe'er+ c%ills+ or weig%t loss) 8%e %eartburn occurs t%ree to four times &er wee() *e %as a long %istory

of tobacco but no alco%ol use) !n u&&er endosco&y s%ows erosi'e eso&%agitis and - cm of Barrett=s$a&&earing

mucosa) Bio&sies are ta(en) 9%ic% of t%e following statements concerning t%is &atient is false

;!< *C bloc(ers at standard doses are minimally effecti'e in treating ERD

;B< 8%e ris( of de'elo&ing eso&%ageal cancer is related to t%e %istology on bio&sy;4< 8%e ris( of de'elo&ing eso&%ageal cancer is a&&roximately .)?2 &er year

;D< 8%ere is clear e'idence t%at an endosco&y e'ery year for sur'eillance will decrease morbidity and mortality

;E< ! &roton$&um& in%ibitor daily s%ould be &rescribed

!nswer:

;D< 8%ere is clear e'idence t%at an endosco&y e'ery year for sur'eillance will decrease morbidity and mortality

Ex&lanation:

Barrett=s eso&%agus is defined by t%e meta&lastic c%ange of t%e sAuamous eso&%ageal mucosa to columnar

mucosa) 8%e ris( of de'elo&ing cancer is de&endent u&on t%e lengt% of t%e mucosa+ t%e age of t%e &atient+ and

t%e %istology) 8%e finding of intestinal meta&lasia and/or dys&lasia increases t%e ris( of de'elo&ing cancer)*owe'er+ t%e ris( of t%e a'erage &atient wit% Barrett=s eso&%agus is a&&roximately .)?2 &er year) Patients

wit%out dys&lasia ;t%e ty&ical &atient< s%ould be treated wit% a &roton$&um& in%ibitor) ! re&eat+ sur'eillance

endosco&y at 1$ to "$year inter'als s%ould be &erformedH %owe'er+ t%ere are no data to demonstrate a decreasein morbidity or mortality by suc% a &ractice)


31/160

astroenterology

Record "1

! 0-$year$old woman &resents to t%e emergency de&artment wit% com&laints of slurred s&eec%+ blurry 'ision+and numbness of t%e left u&&er extremity t%at lasted about ten to fifteen minutes t%is morning) 8%e &atient %ad

similar sym&toms two days earlier) *er &ast medical %istory is significant for recently diagnosed cirr%osis+ for

w%ic% s%e is ta(ing s&ironolactone) 5ital sign are: tem&erature #)F G+ &ulse FC/min+ blood &ressure 1-C/F mm

*g+ and res&iratory rate 1-/min) Laboratory studies re'eal: 9%ite cell count F+0../mm"+ %ematocrit ")#2+ &rot%rombin time ;P8< 11)- seconds+ @7R 1).+ &artial t%rombo&lastin time ;P88< "F) seconds) !n EK s%ows

atrial fibrillation at a rate of F/min) 9%at is t%e next best ste& in t%e management of t%is &atient

;!< Ec%ocardiogram

;B< Diltia>em

;4< Electrical cardio'ersion;D< *e&arin ?+... I bolus+ t%en start %e&arin dri&

;E< !S! "C? mg daily

;G< 4oumadin

!nswer:

;D< *e&arin ?+... I bolus+ t%en start %e&arin dri&

Ex&lanation:

8%e &atient &resents wit% atrial fibrillation leading to a stro(e) 8%e most urgent ste& is to start anticoagulation to

&re'ent a recurrent e&isode) !n ec%ocardiogram certainly does need to be done+ but gi'en t%e %istory of t%e

atrial arr%yt%mia and stro(e+ t%e &atient will need anticoagulation no matter w%at it s%ows) 8%e rate isM1../min+ so diltia>em will not %el&) 8%is &atient is %emodynamically stable+ so electrical cardio'ersion is not

necessary) @n fact+ cardio'ersion wit%out anticoagulation is contraindicated because it mig%t allow anot%er

embolus to de'elo&) @f t%e &atient did not %a'e t%e atrial arr%yt%mia+ t%en as&irin alone would be useful)4oumadin s%ould be started in addition to t%e %e&arin) !s a single agent+ t%e effect of coumadin would not be

ra&id enoug%)


32/160

4ardiology

Record "C

! -.$year$old woman &resents wit% se'ere e&igastric &ain+ nausea+ and 'omiting) 8%e &ain began suddenly and

radiates to t%e bac() P%ysical examination s%ows normal 'ital signs) *owe'er+ s%e is icteric) 8%e abdomen is

tender+ es&ecially in t%e e&igastrium) Laboratory studies s%ow t%e following: amylase "+##. I/L+ !L8 CC. I/L+

!S8 1. I/L+ total bilirubin .)? mg/dL+ and albumin ")? g/dL) !n abdominal ultrasound s%ows numerousgallstones in t%e gallbladder) 9%ic% of t%e following statements concerning t%is &atient is false

;!< !t admission+ a Ranson score of 1 rules out t%e &ossibility of se'ere disease;B< @ntra'enous fluids s%ould be gi'en at a rate of greater t%an C?. mL &er %our for se'eral liters

;4< ! nasogastric tube is not necessary

;D< ! 48 scan is not reAuired to confirm t%e diagnosis;E< ! c%olecystectomy s%ould be &erformed &rior to disc%arge

!nswer:

;!< !t admission+ a Ranson score of 1 rules out t%e &ossibility of se'ere disease

Ex&lanation:

8%e diagnosis of acute &ancreatitis is made in t%e a&&ro&riate clinical scenario ;e&igastric &ain+ nausea+ and

'omiting< in a &atient wit% an amylase greater t%an t%ree times t%e u&&er limit of normal) ! 48 scan is notreAuired to confirm t%e diagnosis in suc% &atients) Se'erity cannot be defined wit%in t%e first - %ours) !

Ranson=s se'erity score greater t%an " defines se'ere disease) *owe'er+ at admission+ t%e score is not accurate

because it ta(es - %ours to com&lete) 7asogastric tubes s%ould be reser'ed for &atients wit% refractory nauseaand 'omiting) 8%e finding of gallstones in t%e gallbladder and t%e ele'ated !S8 and !L8 demonstrate gallstones

as t%e etiology of t%e acute &ancreatitis) ! c%olecystectomy is recommended in &atients wit% gallstone

&ancreatitis) 8%irty &ercent of &atients wit% gallstone &ancreatitis will %a'e a rela&se wit%in " mont%s if t%egallbladder is not remo'ed)


33/160

astroenterology

Record ""

! -1$year$old woman comes to clinic wit% %air loss for t%e &ast mont% and energetically as(s you to refer %er toa J%air s&ecialist)J S%e denies coug%+ fe'er+ or weig%t c%ange but mentions t%at s%e %as constantly felt tired and

%as %ad difficulty concentrating lately) S%e also %as freAuent %eadac%es and muscle cram&s) *er menstrual cycle

is usually regular+ but now s%e %as been %a'ing amenorr%ea for t%e &ast L+ and t%e 'iralµtwo mont%s) S%e is

*@5 &ositi'e+ %er 4D- count is F/ load is undetectable) S%e also %as a %istory of atrial fibrillation+ w%ic% %asreAuired defibrillation se'eral times) Sotalol+ &rocainamide+ and Auinidine %a'e been ineffecti'e in maintaining

%er sinus r%yt%m in t%e &ast) S%e is on >ido'udine+ lami'udine+ nelfina'ir+ trimet%o&rim/sulfamet%oxa>ole+ and

amiodarone) S%e smo(es %alf a &ac( of cigarettes a day) ,n &%ysical examination+ s%e is slig%tly o'erweig%tand %as a tem&erature of #)# G+ a res&iratory rate of 10/min+ and a blood &ressure of 1../?. mm *g) *er s(in is

&ale and dry) *er %air is dry+ but no ob'ious t%inning is noticeable) 8%e t%yroid$gland lobes and ist%mus are

&al&able+ and nodular c%anges are not detected) *er !L8 is C. I/L+ and t%e !S8 is CC I/L) 8%yroid$stimulating%ormone ;8S*< is CC mI/L ;normal .)-$? mI/Lit%romycin and le'ot%yroxine;D< Sto& t%e amiodarone

;E< 4%ange antiretro'iral medications

;G< Start le'ot%yroxine

!nswer:

;G< Start le'ot%yroxine

Ex&lanation:

8%is &atient dis&lays signs of %y&ot%yroidism due to drug toxicity+ w%ic%+ in t%is case+ is from amiodarone)

,t%er agents associated wit% t%is effect are lit%ium+ iodide+ &ro&ylt%iouracil+ amiodarone+ and interferon$al&%a)

Sym&toms of %y&ot%yroidism may be 'ariable) 8%ey may include slow s&eec%+ absence of sweating+consti&ation+ &eri&%eral edema+ &allor+ decreased sense of taste and smell+ and weig%t c%anges) Some women

ex&erience amenorr%ea) alactorr%ea may be &resent) P%ysical findings include goiter+ face &uffiness+

t%ic(ening of t%e tongue+ t%inning of t%e outer %al'es of t%e eyebrows+ %ard &itting edema+ and effusions into &leural+ &eritoneal+ and &ericardial ca'ities) *y&ot%ermia may be &resent) 8%e free 8- le'el is normal or low+

and t%e t%yroid stimulating %ormone ;8S*< le'el is usually ele'ated abo'e C. mI/L) @n t%is case+ t%e &atient

doesn=t dis&lay any ot%er ad'erse effects of sulfonamide t%era&y+ suc% as a ras%+ neutro&enia+ or

t%rombocyto&enia) @t seems reasonable to continue trimet%o&rim/sulfamet%oxa>ole for Pneumocystis &ro&%ylaxis because t%e 4D- cell count is ML) !>it%romycin s%ould not be started for µC../ 3ycobacterium

a'ium intracellulare &ro&%ylaxis because t%e 4D- cell count is NL) !nytime someone needs amiodarone and

de'elo&sµ?./ %y&ot%yroidism+ t%e answer is to treat t%e %y&ot%yroidism and continue amiodarone) Se'eral ot%er

medications and electi'e cardio'ersion did not %el& %er in t%e &ast) S%e needs t%e amiodarone to stay in sinus

r%yt%m)


34/160

Endocrinology

Record "-

! F?$year$old man is broug%t to t%e %os&ital after %e was found lying on t%e floor of %is a&artment) ,nadmission t%e &atient tal(s and tells %is story to t%e &%ysician in t%e emergency room) *e says t%at %e is 'ery

sad because %e lost %is sister two days ago) 8%e family denies t%is %a&&ening) 8%e &atient loo(s confused+ wea(+

and de%ydrated) *is tem&erature is 1..)? G+ wit% a &ulse of 1../min and a blood &ressure of 1../0. mm *g) *e

%as crac(les o'er t%e rig%t lung fields and bruises on t%e outer as&ect of t%e rig%t t%ig%) 8%ere is no fracture &al&ated+ and t%e s(in is intact) *is sodium is 1?. mEA/L+ BI7 is -? mg/dL+ and creatinine is C mg/dL) 8%e

urinalysis is &ositi'e for myoglobin+ and t%ere is an increased s&ecific gra'ity) 8%e di&stic( is &ositi'e for blood+

but on microsco&ic examination t%ere are no red cells) 8%e %ead 48 scan s%ows old+ lacunar infarctions) 8%e &atient is transferred to t%e floor for obser'ation and treatment) During t%e nig%t+ t%e &atient becomes more

disoriented and agitated+ and t%e nurse as(s t%e intern for a restraint order+ but t%e intern decides to gi'e t%e

&atient intramuscular %alo&eridol) 9%ic% of t%e following is t%e most urgent ste&

;!< Kee& t%e room dar( and Auiet

;B< Electrocardiogram;4< Switc% t%e %alo&eridol c%lor&roma>ine ;8%ora>ine<

;D< @ncrease t%e dose of t%e %alo&eridol;E< !dd lora>e&am

!nswer:

;B< Electrocardiogram

Ex&lanation:

8%e EK is t%e correct next ste& because of concerns about r%abdomyolysis) 8%e features t%at suggest se'ere

r%abdomyolysis are t%e bruises of t%e legs+ t%e %istory of lying on t%e floor for a &rolonged &eriod of time+ and

t%e myoglobin in t%e urine) ! &otassium le'el s%ould be c%ec(ed as well) Doing t%e EK first is to exclude t%emost life$t%reatening manifestation of r%abdomyolysis+ w%ic% is an arr%yt%mia from %y&er(alemia) 8%is &atient

%as delirium secondary to trauma+ combined wit% de%ydration and &ossibly infection) Delirium may be

%y&eracti'e+ %y&oacti'e+ or mixed) En'ironmental inter'entions+ suc% as reinforced orientation+ t%e ex&lanation

of all &roceedings+ and a Auiet and calm room are measures t%at can be em&loyed in t%e treatment of delirium) !room wit% low lig%ting is fa'orable in t%e management of delirium+ but a dar( room is contraindicated)

*alo&eridol+ w%ic% is a %ig%$&otency+ anti&syc%otic medication+ can be used to control t%e agitation) 8%e side

effects of %alo&eridol include extra&yramidal sym&toms+ a reduced sei>ure t%res%old+ and &rolongation of t%eQ8 inter'al+ w%ic% can lead to torsades de &ointes) Prolongation of t%e Q8 inter'al of greater t%an -?.

milliseconds warrants telemetry monitoring)

4%lor&roma>ine is anot%er anti&syc%otic medication t%at can be used for t%e treatment of t%e sym&toms ofdelirium) 8%e administration of t%is drug may be associated wit% sedation+ antic%olinergic effects+ and al&%a$

adrenergic bloc(ing effects+ w%ic% may cause %y&otension) Eac% of t%ese side effects may com&licate delirium)

@n t%e elderly+ %alo&eridol may be started as a dose of .)C? to .)? mg e'ery - %ours) 8%ere is no e'idencesu&&orting t%at t%e addition of lora>e&am would be beneficial) Lora>e&am was s%own to %a'e eAual efficacy

w%en com&ared wit% %alo&eridol or c%lor&roma>ine)


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7eurologyRecord "?

! C1$year$old w%ite man comes to t%e emergency de&artment because of muscular wea(ness) *e %as %ade&isodes of wea(ness for t%e &ast year) !fter coming %ome from t%e gym+ %e feels t%e inability to reac% t%e

cabinets in t%e (itc%en) Sometimes %e is unable to rise from a seated &osition) 8%e attac(s occur a&&roximately

" times &er wee(+ last " %ours+ and subside s&ontaneously) 8%e attac(s also occur after %ea'y meals) ,n

&%ysical examination+ you note C/? motor strengt% in t%e bice& muscles bilaterally+ wit% "/? strengt% of t%e%andgri&+ and C/? motor strengt% of t%e Auadrice&s bilaterally+ wit% -/? strengt% on dorsiflexion of t%e feet) *e

%as no &rior medical %istory) Laboratory studies re'eal:

Sodium 1-. mEA/LH &otassium C). mEA/LH c%loride 11C mEA/LH bicarbonate 1? mEA/LH BI7 1. mg/dL+creatinine .) mg/dL)

9%at is t%e next best ste& in t%e management of t%is &atient

;!< Re&eat &otassium le'el

;B< Potassium c%loride orally

;4< !ceta>olamide;D< Potassium c%loride intra'enously

;E< S&ironolactone

!nswer:;D< Potassium c%loride intra'enously

Ex&lanation:

8%is &atient %as an acute attac( of %y&o(alemic &eriodic &aralysis ;*PP


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7e&%rology

Record "0

3r) 7u(i+ a C?$year$old man recently emigrated from 7igeria+ comes to your clinic com&laining of worseningexertional s%ortness of breat%) *is sym&toms %a'e worsened o'er t%e last se'eral mont%s and include t%ree$

&illow ort%o&nea+ &aroxysmal nocturnal dys&nea+ and nocturia) 3r) 7u(i denies any resting or exertional c%est

&ain at t%is time) 5ital signs are: tem&erature #)0 G+ blood &ressure 1C./. mm *g+ %eart rate F?/min and

irregular+ and res&irations 10/min) P%ysical examination is significant for ugular 'enous distention ;5D<worsening on ins&iration+ an S" gallo& wit% "/0 systolic murmur radiating to t%e axilla+ bibasilar crac(les+ and

1 lower extremity edema bilaterally) EK s%ows atrial fibrillation at rate of FC &er minute) Pulmonary

congestion and an enlarged %eart si>e are seen on c%est x$ray) Ec%ocardiogram is significant for reduced left'entricular systolic function+ an eection fraction of CC2+ and decreased myocardial wall t%ic(ness) 9%ic% of

t%e following will result in t%e greatest decrease in mortality

;!< Gurosemide

;B< !miodarone

;4< Beta$bloc(er ;D< Digoxin

;E< S&ironolactone

!nswer:

;4< Beta$bloc(er

Ex&lanation:

8%e &atient %as congesti'e %eart failure) Because t%is &atient is young ;C? years of age


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4ardiology

Record "F

! 0?$year$old man &resents to your clinic for a second follow$u& 'isit) 8wo mont%s ago+ %e was %os&itali>ed for

an acute myocardial infarction) *e currently denies c%est discomfort+ &al&itations+ s%ortness of breat%+ fe'er+ or

coug%) *is &ast medical %istory is significant for %y&ertension and %y&erc%olesterolemia) *e Auit smo(ing t%ree

wee(s ago after a ".$&ac($year smo(ing %istory)

P%ysical examination re'eals a @@/5@ systolic murmur at t%e a&ex wit% a diffuse and dis&laced a&ical im&ulse)

7o ugulo'enous distension+ rubs+ or &eri&%eral edema is noted) 8%e lungs are clear bilaterally) Blood &ressureis 1?F/# mm *g+ res&irations are 10/min+ &ulse is F./min+ and tem&erature is #)F G) EK s%ows a sinus

r%yt%m at 0 b&m) Q wa'es are noted in leads 51$5"+ along wit% 1 mm of S8$segment ele'ation in t%e anterior

leads+ unc%anged from %is last office 'isit t%ree wee(s ago) Laboratory studies s%ow: sodium 1-1 mEA/L+ &otassium -)1 mEA/L+ c%loride 1.# mEA/L+ 4,C C? mEA/L+ BI7 11 mg/dL+ creatinine .) mg/dL+ ESR C0

mm/%+ 9B4 +C../mm"+ %emoglobin 1- mg/dL+ %ematocrit -12+ and &latelets CC#+.../mm") 9%at is t%e most

li(ely diagnosis

;!< !nterior wall myocardial infarction;B< 5entricular aneurysm

;4< Dressler=s syndrome;D< Rig%t %eart failure

;E< Pericarditis

!nswer:

;B< 5entricular aneurysm

Ex&lanation:

8%e &atient most li(ely %as de'elo&ed a 'entricular aneurysm) *is %istory of a myocardial infarction se'eral

wee(s to mont%s ago combined wit% t%e absence of sym&toms are consistent wit% t%is disorder) *e %as no

sym&toms today+ ma(ing a new infarction unli(ely) Dressler=s syndrome would eit%er gi'e &leuritic c%est &ain

altering wit% body &osition and res&iration and a rub+ or it would gi'e diffuse S8$segment ele'ation in 'irtuallyall t%e leads) Rig%t %eart failure would gi'e %y&otension+ dys&nea+ and t%e ugular 'enous distension and

&eri&%eral edema consistent wit% t%e bac(flow of blood into t%e 'enous system) !lso+ rig%t %eart failure usually

acutely de'elo&s in association wit% inferior wall infarctions+ not anterose&tal infarctions+ suc% as t%is &atientseems to %a'e %ad) !n ec%ocardiogram is needed to confirm t%e diagnosis)


38/160

4ardiology

Record "

! "-$year$old woman wit% se'ere %eartburn &resents for treatment) S%e re&orts %eartburn " to - times &er wee( but no dys&%agia+ nausea+ or 'omiting) S%e %as a busy lifestyle and wor(s . %ours &er wee() S%e consumes

one meal &er day in t%e e'ening) *owe'er+ s%e %as been gaining weig%t o'er t%e &ast year) !lt%oug% s%e smo(es

one &ac( of cigarettes &er day+ s%e is &%ysically acti'e) 8%ere %as been no %os&itali>ations or surgeries) 9%at

would be t%e most a&&ro&riate course of treatment

;!< Proton$&um& in%ibitors daily for " mont%s

;B< Lifestyle modification;4< !n u&&er endosco&y

;D< I&&er gastrointestinal series

;E< C-$%our &*

!nswer:

;B< Lifestyle modification

Ex&lanation:

Lifestyle modification for t%is &atient would be eating t%ree meals &er day ;as o&&osed to one large meal


39/160

astroenterology

Record "#

! ".$year old woman comes to your office for e'aluation of dee& 'enous t%rombi) Last year s%e de'elo&ed a

lower extremity 'enous clot) S%e was on oral contrace&ti'es but %as subseAuently sto&&ed) S%e was successfullytreated wit% coumadin for six mont%s) 8%ree wee(s ago s%e de'elo&ed a femoral 'enous t%rombosis+ and now

s%e is again treated wit% coumadin) *er mot%er died of a &ulmonary embolus+ and %er aunt on %er mot%er=s side

%ad a %istory of 'enous t%rombosis)

!ll routine laboratory studies are normal+ including t%e com&lete blood count+ &rot%rombin time+ acti'ated

t%rombo&lastin time+ and li'er function tests) S%e %as a test t%at is &ositi'e for t%e factor 5 leiden mutation by

&olymerase c%ain reaction ;P4R


40/160

*ematology$,ncology

Record -.

! "0$year$old man comes to t%e *@5 clinic for a regular follow$u& 'isit) *e %as been (nown to be *@5 &ositi'e

for t%ree years) !ntiretro'iral treatment was started six mont%s ago) *is &resent regimen includes >ido'udine+lami'udine+ nelfina'ir+ a>it%romycin+ and Bactrim ;trimet%o&rim/sulfamet%oxa>ole


41/160

@nfectious Diseases

Record -1

! C#$year$old woman wit% a %istory of systemic lu&us eryt%ematous ;SLE< for t%e last - years comes for

e'aluation of malaise+ nausea+ 'omiting+ and de&ression) S%e currently denies oint &ain) 8%ree years ago+ t%e

&atient was gi'en steroids but sto&&ed t%em on %er own w%en s%e became &regnant) I&on examination+ t%e

&atient %as a %eart rate of -/minute and a blood &ressure of 10C/# mm *g) Laboratory studies s%ow a%ematocrit of CF)-2+ wit% a serum creatinine of ")Fmg/dL and &otassium of -)# mEA/L) *er urinalysis %as C

&rotein and C?$?. red blood cells/%&f) Regarding renal bio&sy+ w%ic% one of t%e following is t%e best answer

;!< @t is not indicated in t%is &atient

;B< @t is mandatory in a &atient wit% &ositi'e lu&us serology to rule out lu&us ne&%ritis

;4< Bio&sy is used to determine t%e need for cyclo&%os&%amide;D< @t is indicated only in rela&se &atients

;E< @t is indicated in drug$induced lu&us

!nswer:

;4< Bio&sy is used to determine t%e need for cyclo&%os&%amide

Ex&lanation:

4linical lu&us ne&%ritis is seen in ?.2 of SLE &atients and is c%aracteri>ed by eit%er urinary abnormalities or arising creatinine) Establis%ing a s&ecific diagnosis of renal lu&us is im&ortant+ as eac% class may need a different

form of t%era&y) 3esangial lu&us ne&%ritis reAuires a s%ort course of &rednisone+ w%ereas diffuse &roliferati'e

lu&us ne&%ritis reAuires a %ig%er dose of &rednisone+ along wit% an immunosu&&ressant+ li(e a>at%io&rine orcyclo&%os&%amide) E'en if &roteinuria is mild+ renal bio&sy is still indicated) ou cannot adeAuately &redict t%e

nature of t%e renal disease or t%e need for cyclo&%os&%amide from t%e degree of &roteinuria) ! re&eat bio&sy is

also indicated for late &rogression of t%e disease to distinguis% between acti'e lu&us+ w%ic% is treated wit%immunosu&&ressants+ from scarring due to &re'ious inflammatory inury+ w%ic% is treated wit% !4E in%ibitors)

Patients wit% a slow rise in creatinine may or may not need t%era&y) 8%e bio&sy will %el& to distinguis% between

(idneys t%at are sim&ly fibrotic or sclerotic from t%ose wit% diffuse &roliferati'e ne&%ritis) Sclerosis will not

res&ond to immunosu&&ressi'e t%era&y+ w%ereas &roliferati'e lesions will) 3ost rela&ses of SLE do not in'ol'et%e (idney) ! fall in com&lement le'els is a more 'aluable &redictor of subseAuent rela&se) 7e&am

practiceexam1 & 2

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