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Posted by baba from IP on August 06, 2014 at 04:30:54:

A 67-year-old woman presents to a clinic for review
of her medications. She has had a history of
hypertension for 25 years, type 2 diabetes for 20
years and congestive heart failure for five years.
She is a former smoker of 2 packs of cigarettes per
day and her lipid status is not known at this time.
Her current medications include nifedipine,
hydralazine, isosorbide dinitrate, glyburide, a
multivitamin, and conjugated estrogens. Today in
the office, her blood pressure is 160/90 mm Hg, her
fasting blood glucose is 210 mg/dL and her
hemoglobin A1c is 7.1%. She reports moderate
dyspnea on exertion, unchanged from previous
visits. Which of the following is the most appropriate
intervention at this time?

A. Increase her glyburide dosage

B. Increase her nifedipine dosage

C. Discontinue her hydralazine therapy

D. Discontinue the hydralazine and add

E. Begin simvastatin therapy


The correct answer is D. This patient has poorly
controlled hypertension and poorly controlled
diabetes. She needs improved therapy for both, the
issue is, how best to do that. The concept
underlying this question is the absolute importance
of beginning ACE inhibitor therapy on both Type 1
and Type 2 diabetics. Many clinical trials have
shown the beneficial effects of ACE inhibitors on
preventing nephropathy and slowing the
progression of established nephropathy in
diabetics. It is the standard of care that all diabetics
be given an ACE inhibitor if they are able to
tolerate its blood pressure effects. Given that she
has congestive heart failure and hypertension, the
ACE inhibitor also will be efficacious in their
treatment as well. In fact, ACE inhibitors have been
shown to be superior to hydralazine and isosorbide
dinitrate in terms of morbidity and mortality in
treatment of CHF; all patients with symptomatic
CHF, regardless of ejection fraction, should be
placed on one.

Increasing her glyburide dosage (choice A) may
be appropriate given her glucose level and
hemoglobin A1c, but not as important as beginning
therapy with an ACE inhibitor.

Increasing her nifedipine dosage (choice B) might
help control her blood pressure, but fails to address
the superiority of a single agent, an ACE inhibitor
for both blood pressure control and prevention of
diabetic nephropathy.

Discontinuing her hydralazine therapy (choice C)
is incorrect because her BP is already poorly
controlled and this would not assist in improved

Beginning simvastatin therapy (choice E) is not
appropriate until her lipid status in known. These
drugs have been shown to be beneficial for both
primary and secondary prevention of myocardial
infarction, but should not be prescribed in the
absence of lipid data.

An 8-year-old boy falls on his right hand with the arm
extended, and he breaks his elbow by
hyperextension. X-ray films show a supracondylar
fracture of the humerus. Which of the following
complications is of greatest concern with this type of

A. Instability that requires open reduction
and internal fixation

B. Insufficient remodeling

C. Growth plate damage

D. Malunion

E. Vascular and nerve injuries


The correct answer is E. In general, fractures in
children pose fewer problems than fractures in
adults. However, this particular lesion in children is
prone to result in vascular or nerve injuries and
requires close follow-up immediately after it has
been reduced and immobilized.

Open reduction and internal fixation (choice A) are
not necessarily the rule in these cases. Closed
reduction is usually possible.

Remodeling (choice B) is invariably excellent in
fractures in children, and this one is no exception.

Growth plate damage (choice C) occurs only when
the fracture crosses the joint or when the growth
plate is crushed, neither of which is the case here.

Malunion (choice D) in the upper extremity is the
big fear with displaced navicular fractures, but not
with humeral fractures.

A 45-year-old white woman presents to her primary
care physician for her routine yearly examination.
Her physician notices that she has lost
approximately 25 lb over the past year. When asked
about her weight loss, she states that she has not
had much of an appetite since her daughter left to
go to college about 8 months ago. In describing this,
she is somewhat tearful and complains of loneliness,
poor memory, decreased concentration, and feeling
tired. Although she appears very sad, she denies
feeling depressed, and states that she simply needs
to become more socially active to distract herself
from her worries. Her physical examination is normal
except for the noticeable weight loss. She weighs
105 lb. Which of the following is the most likely

A. Adjustment disorder with anxiety

B. Bereavement

C. Dependent personality disorder

D. Dysthymic disorder

E. Major depressive disorder


The correct answer is E. The probable diagnosis
is major depressive disorder. In order to meet
criteria for this disorder, the patient must have five
or more symptoms during the same two-week
period. This patient has several such symptoms:
she appears sad (depressed affect), she has
significant weight loss, she describes feeling
fatigued, and she complains of poor concentration.
Other symptoms that she may be experiencing
include: diminished interests or pleasure
(anhedonia), changes in sleep habits (insomnia or
hypersomnia), psychomotor agitation or
retardation, feelings of worthlessness or
inappropriate guilt, and suicidal ideation.

Adjustment disorder with anxiety (choice A) is the
diagnosis when the development of significant
anxiety symptoms is in response to identifiable
stressors within 3 months of the onset of the
stressor. The stress-related disturbance does not
meet criteria for another specific Axis I disorder.

Bereavement (choice B) refers to the state of
being deprived of someone by death, and it refers
to being in a state of mourning. Although the
patient's daughter recently left for college, the
patient's symptoms can not be accounted for by

Dependent personality disorder (choice C) refers
to a chronic and pervasive personality structure in
which the patient has an excessive need to be
taken care of. This leads to submissive and
clinging behavior and fears of separation,
beginning by early adulthood and present in a
variety of contexts. There is no evidence from this
case that the patient has such personality features.

Dysthymic disorder (choice D) refers to a milder
form of depression that lasts for at least 2 years (or
at least one year in children and adolescents).
Patients exhibit two or more depressive symptoms.
There is no evidence that this patient's symptoms
are chronic.

A 29-year-old woman comes to the physician for
follow-up of a right breast lump. The patient first
noticed the lump 4 months ago. It was aspirated at
that time, and cytology was negative, but the cyst
recurred about 1 month later. The cyst was
re-aspirated 2 months ago and, again, the cytology
was negative. The lump has recurred. Examination
reveals a mass at 10 o'clock, approximately 4 cm
from the areola. Ultrasound demonstrates a cystic
lesion. Which of the following is the most appropriate
next step in management?

A. Mammography in 1 year

B. Ultrasound in 1 year

C. Tamoxifen therapy

D. Open biopsy

E. Mastectomy


The correct answer is D. Breast lumps are a
common complaint in women. Many of these
masses are benign processes. Benign conditions of
the breast include fibrocystic disease,
fibroadenomas, galactoceles, abscesses, and
necrosis. It is appropriate to aspirate a palpable
macrocyst in the breast; the fluid should be placed
on a slide and sent for cytologic evaluation. If the
cytology is negative, no further treatment is
needed. Some would argue that if the cyst recurs, it
may be aspirated again. However, when a lesion
recurs twice, as has occurred in this patient, open
biopsy is warranted.

To wait to perform mammography in 1 year (choice
A) or ultrasound in 1 year (choice B) would be
incorrect management. First, if a malignancy is
present, waiting another year will allow progression
of the cancer. Second, the mammogram is not
definitive. Imaging can contribute information to the
workup of a breast mass, but the definitive
diagnosis rests on histologic evaluation.

Tamoxifen therapy (choice C) is used to both
prevent and treat breast cancer. However, this
patient does not yet have a diagnosis. She has a
cystic mass that has been aspirated twice and has
recurred twice. She therefore requires a biopsy to
establish a diagnosis prior to the institution of any

Mastectomy (choice E) would not be indicated for
this patient. Again, this patient does not have a
diagnosis, and to perform a mastectomy for a
recurrent cyst would be inappropriate.

A 42-year-old woman hit her breast with a broom
handle while doing housework. She noticed a lump
in that area at the time, and 1 week later the lump
was still present. She then sought medical advice.
On physical examination, she has a 3-cm, hard mass
deep inside the affected breast, and some superficial
ecchymosis over the area. Which of the following is
the most appropriate next step, or steps, in

A. Reassess in about 2 months, with no
specific therapy

B. Hot packs, analgesics, and surgical
evacuation of the hematoma

C. Mammogram, and no further therapy if the
report does not identify cancer

D. Mammogram and biopsy of the mass

E. Mastectomy


The correct answer is D. Although the history of
trauma might suggest a hematoma or fat necrosis,
it is well known that trivial trauma sometimes brings
to the attention of the patient an area of the body
that had not been examined before. A breast mass
in a 42-year-old woman requires a mammogram
and biopsy.

Waiting 2 months (choice A) would be
unacceptable for a potential cancer.

Hot packs and analgesics (choice B) on the
assumption that this is a hematoma would also
delay the diagnosis if a cancer is present.
Furthermore, if this is indeed a hematoma one
would not necessarily want to drain it.

Choice C is incorrect because the mammogram is
an adjunct to the biopsy of a breast mass, not a
substitute for it. The two studies are

Mastectomy (choice E) is too radical a step before a diagnosis has been established.

A 52-year-old, obese African American woman is
admitted to the hospital for an elective gastric bypass
operation for weight reduction. On post-op day 1, the
patient acutely develops tachypnea, tachycardia, and
an oxygen requirement of 4 L. She complains of
left-sided pleuritic chest pain. Which of the following
is the most appropriate diagnostic study?

A. Chest x-ray

B. CT scan

C. ECG with rhythm strip


E. Ventilation-perfusion scan


The correct answer is E. The most likely diagnosis
in this case is pulmonary embolus (PE). The risk
factors for this patient are obesity and surgery.
Pleuritic chest pain can develop in patients with a
PE. Tachycardia, tachypnea, and increased oxygen
requirements are highly suggestive of the diagnosis.
The most appropriate test to confirm the clinical
suspicion is a ventilation-perfusion scan.

A chest x-ray (choice A) can suggest a PE by
showing a wedge-shaped area if there is an infarct;
however, this is not the most sensitive or specific
test to confirm the diagnosis. Chest x-ray films are
most often normal.

A CT scan (choice B), like a chest x-ray, may reveal
an area of infarct, but is not the most appropriate
test in this scenario.

An ECG with rhythm strip (choice C) might show
tachycardia, possible right axis deviation due to
pulmonary hypertension, and right ventricular strain
with ST-T wave changes. But, the most common
finding is a normal ECG.

MRI (choice D) is used to show soft tissue
abnormalities and is most often used in neurologic
and orthopedic diagnoses. It would not be the test of
choice for PE.

A 23-year-old professional basketball player
presents to the team physician 3 hours before game
time complaining of abdominal pain. The symptoms
began approximately 8 hours earlier in a diffuse
fashion. Two hours later, he began feeling
nauseated and vomited twice. Over the past 4 hours,
the abdominal pain has become more severe and
well localized in the right lower quadrant. His
examination now reveals well-localized pain in the
right lower quadrant inferolateral to the umbilicus.
Which of the following is the most likely diagnosis?

A. Acute obstruction of the appendiceal
lumen by a fecalith

B. Acute onset of ileocolitis

C. Acute onset of ischemic colitis

D. Acute Yersinia infection

E. Obstruction of the ileocecal valve by a


The correct answer is A. Acute appendicitis is the
second most common cause in the U.S., behind
hernia, of severe acute abdominal pain that
requires abdominal operation. Although it can occur
at all ages, many patients, like this man, are
teenagers or young adults. This patient's
presentation is typical for acute appendicitis, with
initially poorly localized pain that is followed by
nausea and vomiting. In classic appendicitis, the
pain shifts to the right lower quadrant, where it
becomes more localized. In most patients, acute
obstruction of the appendiceal orifice by a fecalith
initiates the acute appendicitis.

The acute onset of ileocolitis (choice B) will
produce diarrhea or bloody stools.

There is no evidence to suggest an etiology for
ischemic colitis (choice C), which will typically
present with bloody diarrhea and often with
left-sided abdominal pain.

Acute Yersinia infection (choice D) will produce
acute right lower quadrant findings similar to those
of acute appendicitis. However, it is accompanied
by diarrhea, which is not described in this case.

There is no reason to suspect obstruction of the
ileocecal area by any mass (choice E) in a
23-year-old man. Such an obstruction, should it
occur, would typically present with abdominal
distention as a result of bowel obstruction.

A 24-year-old woman sustains multiple injuries in a
car accident, including a pelvic fracture. She is
hemodynamically stable. Initial assessment shows
no vaginal or rectal injuries; however, when a Foley
catheter is inserted, bloody urine is recovered.
Which of the following would be the best way to
evaluate her urologic injury?

A. Sonogram of the bladder

B. Intravenous pyelogram

C. Cystoscopy

D. Retrograde cystogram including
post-void films

E. Retrograde cystogram including views of
the ureters


The correct answer is D. Bloody urine plus pelvic
fracture equals bladder injury in either gender, or
bladder or urethral injury in the male. In this case,
with the very short and well-protected female
urethra not being suspected, only the bladder is
the obvious candidate. Injecting dye and taking
x-ray films will show the extravasation, but it is
important to include post-void films because
extravasation at the bladder neck can be obscured
by the dye that is filling the bladder.

Sonogram (choice A) is a good, noninvasive way
to look at things, but here we can get far better
detail with a study (the retrograde cystogram) that
is not particularly invasive.

Intravenous pyelogram (choice B) would show dye
extravasation, but with far less detail than that
provided by direct injection.

Cystoscopy (choice C) would be invasive and not
easy to do. When a cystoscopy is done, fluid is
injected into the bladder to expand it and see the
walls. In this case, the injected fluid would go out
into the peritoneal cavity or the preperitoneal

Looking at the ureters (choice E) is not necessary
when bladder injury is suspected. The ureters are
rarely injured in blunt trauma.

A 7-year-old boy is brought to the clinic for a lifetime
history of bedwetting. He has otherwise been
completely healthy and has met all development
milestones. His parents deny a history of trauma,
and the history is not consistent with abuse. The
patient has been wetting every night but not during
the daytime. He has no incontinence. Which of the
following is the most appropriate next step in his

A. Intravenous pyelogram

B. Renal ultrasound

C. 24-hour urine collection

D. Urinalysis

E. CT of pelvis


The correct answer is D. Given the fact that this
patient has had a lifelong history of bedwetting, the
initial evaluation will include a urinalysis to rule out
infection or bleeding. No neurologic dysfunction
exists in this case.

An intravenous pyelogram would be needed to
evaluate for renal failure or chronic urinary tract
infections (choice A).

A renal ultrasound would help evaluate structural
damage but is not indicated in the initial evaluation
(choice B).

24-hour urine collection is commonly done in the
evaluation of nephropathy in diabetics (choice C).

A CT scan at this time would not be indicated at
this stage of evaluation (choice E).

A 72-year-old alcoholic man is brought to the
emergency department by his children. They state
that he has become increasingly confused over the
past week and is unsteady on his feet. On physical
examination, ataxic gait, bilateral paresis of the
lateral gaze, and vertical and horizontal nystagmus
are noted. Which of the following is the most
appropriate next step in management?

A. Administration of IV dextrose

B. Administration of IV mannitol

C. Administration of IV thiamine

D. CT of the brain with contrast

E. Lumbar puncture and examination of the


The correct answer is C. This patient has
Wernicke encephalopathy. This acute disorder
occurs most commonly in chronic alcoholics and
consists of a clinical triad of ophthalmoplegia,
ataxia, and global confusion. Affected patients may
complain of double vision or difficulty with balance.
There is almost always horizontal nystagmus on
lateral gaze. Vertical nystagmus may be present in
50% of cases. Bilateral, often asymmetric, lateral
rectus palsies are characteristic and may develop
rapidly. Bilateral ptosis or an apparent internuclear
ophthalmoplegia occurs rarely. The treatment is
immediate IV thiamine. If given quickly enough,
recovery begins promptly. Nearly all patients with
Wernicke encephalopathy recover from the global
confusional state, but many are left with a residual
disorder of memory (Korsakoff syndrome).

If IV dextrose (choice A) is given before thiamine,
the encephalopathy may worsen.

IV mannitol (choice B) is helpful in conditions
associated with increased intracranial pressure.

CT of the brain with contrast (choice D) is an
appropriate step but not the next appropriate step
in management. IV thiamine should be given first.
CT scan of the head is helpful to evaluate for
structural lesions, such as subdural hematoma.

Lumbar puncture and examination of CSF (choice
E) is not the most appropriate next step either. In
the workup of this patient, a lumbar puncture may
help evaluate for a chronic infection, such as
syphilis or tuberculosis or other processes causing
those symptoms.

After a grand mal seizure, a 32-year-old epileptic
woman notices pain in her right shoulder, and she
cannot move it. She goes to a minor emergency
clinic, where she has a limited physical examination
and anteroposterior (AP) x-ray films of her shoulder.
The films are read as negative, and she is diagnosed
as having a sprain and given pain medication. The
next day, she still has the same pain and is unable to
move her arm. She comes to the emergency
department holding her arm close to her body, with
her hand resting on her anterior chest wall. Which of
the following is the most likely diagnosis?

A. Acromioclavicular separation

B. Anterior dislocation of the shoulder

C. Articular cartilage crushing

D. Posterior dislocation of the shoulder

E. Torn teres major and minor muscles


The correct answer is D. The mechanism of injury
(massive contraction of all muscles in the area) and
the missed diagnosis on a single view AP x-ray film
are classic for posterior dislocation of the shoulder.
Axillary view x-ray films are needed to make the

Acromioclavicular separation (choice A) would
have been obvious on physical examination and on
the x-ray film taken

Anterior dislocation (choice B) is far more common
than posterior dislocation. However, it happens with
regular trauma, has a very typical posture where
the arm is held close to the body but the forearm
and hand are rotated out as if ready to shake
hands, and is easily seen on x-ray films.

Crushing of the articular cartilage (choice C) and
tearing of shoulder girdle muscles (choice E) are
not common injuries following seizures.

A 50-year-old man is brought to the emergency
department complaining of light-headedness. He has
a history of lung cancer, which was diagnosed a
month ago and found to be widely metastatic to the
bone and pericardium. On physical examination, his
blood pressure is 70/40 mm Hg, and his pulse is
100/min. His heart sounds are distant and soft. His
ECG demonstrates low voltage, and electrical
alternans is present. A chest x-ray film shows that the
cardiac silhouette has a "water bottle"
appearance.Which of the following is the most
appropriate intervention in this patient?

A. Beta-blockers

B. Nonsteroidal anti-inflammatory drugs

C. Steroids

D. Pericardiocentesis

E. Cardiac catheterization


The correct answer is D. This patient is in
pericardial tamponade, most probably as a result of
his malignancy. Lung cancer is particularly likely to
cause pericardial effusions. Furthermore, since this
patient has metastases to the pericardium, he might
be bleeding into the pericardial space. This
tamponade may be the cause of his significant
hypotension and the soft cardiac sounds. Electrical
alternans, a phenomenon in which the QRS
changes axis, is indicative of pericardial effusion,
since the heart is moving freely in the fluid, causing
a change in axis noted on the ECG. Emergently, this
patient needs decompression of the pericardial
space with the aid of pericardiocentesis, whereby a
catheter directly drains the fluid in the pericardial

Beta-blockers (choice A) would be of no benefit in
treating cardiac tamponade.

Nonsteroidal anti-inflammatory drugs (NSAIDs)
(choice B) can be useful in treating pericarditis,
which may cause pericardial effusions. However,
this is a longer term option and will have little utility

Steroids (choice C) may similarly be used in
pericarditis, after NSAIDs have failed. However, this
is an option to be explored after the pericardial fluid
has been drained.

Cardiac catheterization is often used to confirm the
diagnosis of tamponade (choice E). Typically the
pressure equalizes across the right atrium and
ventricle. However, emergently, this patient should
have pericardiocentesis.

An 8-month-old infant, who is up-to-date with his
immunizations, is brought to the clinic by his mother.
The mother states that she overheard other mothers
talking about a varicella vaccination that their
children have received. She does not want her son
to have the chickenpox virus and therefore, wants
him to receive the vaccine today. The physician
explains that the infant has not yet reached the
recommended age for the vaccine. If this visit is in
November, when is the earliest that this patient can
return for the varicella vaccine?

A. February

B. March

C. April

D. May

E. June


The correct answer is B. The varicella vaccine is
recommended at any visit on or after the first
birthday (12 months) for susceptible children
(those who have not had the virus).

February (choice A) is incorrect because the
infant will be 11 months.

April, May, and June (choices C, D, and E) would
all be appropriate times to receive the varicella
vaccine except that the question asks for the
earliest possible date.

A general summary of routine immunizations is as

Hep B vaccine- At birth, 1 month, and 6 months

DTaP- At 2, 4, and 6 months, 15-18 months, and
4-6 years

Td booster- 11-12 years, and then every 10 years

Hib- At 2, 4, and 6 months, and 12-15 months

IPV- At 2 and 4 months, 6-18 months, and 4-6

MMR- At 12-15 months and 4-6 years

Varicella- 12 months

A 59-year-old man presents to his primary care
physician with fever and chills. His past medical
history is significant for osteoarthritis for many years.
He has a long smoking history of greater than 150
pack-years. He routinely takes only a non-steroidal
anti-inflammatory agent for pain. He presents with 5
days of fever and chills associated with a productive
cough. He has not been hospitalized recently and
lives at home with his wife and has no sick contacts.
On physical examination he is comfortable, his
temperature is 38.9 C (102 F) and has bibasilar
crackles heard best at the left base. Which of the
following is the most appropriate next step in

A. Arterial blood gas

B. Chest radiograph

C. Complete blood count

D. Oxygen saturation check

E. Sputum gram stain


The correct answer is B. The suspicion, based
upon the clinical examination, is that this patient
has pneumonia. The only way to definit

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