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Posted by baba from IP on August 06, 2014 at 04:51:05:

A 64-year-old man is brought to the emergency
department by his wife because of severe epigastric
distress and nausea that began soon after dinner.
The patient says that it is probably "just indigestion,"
but he appears pale, sweaty, and restless. His blood
pressure is 130/70 mm Hg, pulse is 110/min with
occasional premature beats, and respirations are
20/min. The lungs are clear to auscultation. Heart
sounds are slightly softer than normal, but there are
no murmurs. Which of the following is the most
appropriate initial diagnostic step?

A. Chest x-ray

B. Complete blood count

C. Echocardiography


E. Upper endoscopy


The correct answer is D. Not infrequently, the
symptoms of myocardial ischemia are interpreted by
patients as of gastrointestinal origin (gastric upset,
heartburn, indigestion). However, myocardial
infarction (MI) is usually accompanied by objective
signs of sympathetic activation, including sweating,
anxiety, tachypnea, and tachycardia. Additional
symptoms may include light-headedness, dyspnea,
orthopnea, cough, nausea, and syncope. An ECG
examination is imperative in any patient presenting
with this symptomatology. A normal tracing is rare
with acute MI.

Chest x-ray (choice A) would not be useful in this
case, since there are no physical signs pointing to
the lungs as a possible source of symptoms.

A complete blood count (choice B) would likely
show leukocytosis on the second day following MI,
but it is of little diagnostic value in the initial
approach. On the other hand, serum CK-MB
isoenzyme levels are elevated within 6 hours after
the onset of symptoms.

Echocardiography (choice C) is a helpful
adjunctive tool in demonstrating abnormal motility of
ischemic segments of the ventricular wall following
an MI. However, it is not used as an initial
diagnostic test prior to obtaining an ECG.

Upper endoscopy (choice E) with biopsy is the
standard diagnostic tool in the study of
gastroesophageal reflux disease, which manifests
with postprandial burning epigastric or substernal
pain relieved by antacids.

A 6-week-old male infant who was born at 32 weeks'
gestation with a birth weight of 1500 g, has had an
average weight gain of 8 g/day since birth. He takes
an iron-fortified formula that is 24 kcal/oz. His calorie
intake is about 125 kcal/day. It is noted that his stool
is poorly formed and bulky. Which of the following
dietary modifications will most likely result in
decreased steatorrhea and improved weight gain?

A. Add pancreatic enzymes to the formula

B. Change to a lactose-free formula

C. Increase calorie intake to 175 kcal/day by
increasing volume per feed

D. Substitute medium-chain triglycerides
for long-chain triglycerides

E. Supplement with vitamins A and E


The correct answer is D. The infant in this clinical
vignette has steatorrhea, as evidenced by poorly
formed and bulky stools and poor weight gain. One
of the most important reasons for steatorrhea in
newborns is bile acid deficiency. Bile acids are very
important in normal absorption of fat, which
constitutes a major portion of an infant's calories
intake. Unfortunately, the bile acid pool in neonates
is very small when compared with that in adults. In
addition, neonates often lose an excessive amount
of bile acids in their stools. This results in
physiologic steatorrhea because of poor absorption
of fat. Preterm infants, like the one described in this
clinical vignette, have an even smaller bile acid
pool and are more likely to have steatorrhea
because of poor fat absorption. This will result in
poor weight gain. The solution to this problem is to
substitute medium-chain triglycerides (MCTs) in the
formula for long-chain triglycerides (LCTs),
because, unlike LCTs, MCTs do not require bile
acids for absorption.

Adding pancreatic enzymes (choice A) offers no
help in this case because the problem is not a lack
of pancreatic enzymes.

Changing to a lactose-free formula (choice B) will
not correct the steatorrhea.

Increasing volume per feeding (choice C) without
substituting MCTs for LCTs will only worsen the

In steatorrhea, fat-soluble vitamins, such as A and
E, are lost in the stool. However, supplementing
vitamins A and E (choice E) still cannot correct the

A 48-year-old man presents to a primary care
physician because of a one-week history of
symptoms consistent with pneumonia. Since this is
the patient's first visit to the clinic, the physician
gathers a full history for a new patient assessment.
The patient has no significant past medical, surgical,
or psychiatric history. Family history is significant for
a brother and an uncle with paranoid schizophrenia.
Social history reveals that the patient lives alone,
has minimal contact with family, and describes no
real social activities or friends. When questioned
about this, he states, "I've never been much
interested in my family or being around people. "He
has worked delivering newspapers for the past 15
years. He has not dated since having one girlfriend
in the 11th grade. During interview, though he seems
emotionally detached, he denies depressive
symptoms or psychotic symptoms. Which of the
following is the most appropriate psychiatric

A. Avoidant personality disorder

B. Psychotic disorder, not otherwise

C. Schizoid personality disorder

D. Schizophrenia, undifferentiated type

E. Social phobia


The correct answer is C. Schizoid personality
disorder is a cluster A personality disorder
(paranoid, schizoid, schizotypal). These disorders
are more common in the biological relatives of
patients with schizophrenia than among control
groups. Schizoid individuals are characterized by a
pervasive pattern of detachment from social
relationships and a restricted range of emotional
expression. Such people usually neither desire nor
enjoy relationships with family or friends, choose
solitary activities, have little interest in sexual
experiences with another person, take pleasure in
few (if any) activities, appear indifferent to praise or
criticism of others, and show emotional detachment.

Avoidant personality disorder (choice A) is a
cluster C personality disorder (avoidant,
dependent, obsessive compulsive) characterized by
a high anxiety level. These individuals have a
pervasive pattern of social inhibition, feelings of
inadequacy, and hypersensitivity to a negative
evaluation. They avoid occupational activities that
involve significant interpersonal contact because of
fears of criticism or disapproval. Avoidant
individuals are hesitant in relationships because of
fears of being shamed or ridiculed and view
themselves as socially inept, personally
unappealing, or inferior to others. Unlike in schizoid
personality disorder, avoidant individuals strongly
desire closer relationships, but are very anxious
about them.

Psychotic disorder, not otherwise specified (choice
B) is a diagnosis that indicates psychotic symptoms
(delusions, hallucinations, disorganized speech,
grossly disorganized or catatonic behavior) about
which there is inadequate information to make a
specific diagnosis.

Schizophrenia, undifferentiated type (choice D) is
a diagnosis used to classify individuals who meet
criteria for schizophrenia, but do not clearly fit into
one of the other types (catatonic, disorganized,
paranoid, residual). This patient does not have
known psychotic symptoms.

Social phobia (choice E) is a primary anxiety
disorder that has many features in common with
avoidant personality disorder. It is characterized by
a marked and persistent fear of social situations in
which the person is exposed to unfamiliar people or
to possible scrutiny by others. The individual fears
that he or she will act in a way (or show anxiety
symptoms) that will be humiliating or embarrassing.

A 26-year-old nulligravid woman comes to the
emergency department because of severe right
lower quadrant pain. She states that the pain started
last night. This morning she was awakened from
sleep with severe pain in the same area. During the
episode of pain she also had nausea, vomiting, and
diaphoresis. On admission to the emergency
department she required 5 mg of morphine to control
her pain. Examination is significant for right lower
quadrant tenderness and a tender right adnexal
mass on pelvic examination. Urine hCG is negative.
Urinalysis is negative. Transvaginal ultrasound
reveals an 8 cm right ovarian mass. Which of the
following is the most likely diagnosis?

A. Appendicitis

B. Ectopic pregnancy

C. Nephrolithiasis

D. Ovarian torsion

E. Pelvic inflammatory disease


The correct answer is D. This patient's
presentation is most consistent with ovarian
torsion. Ovarian torsion typically occurs in the
setting of an adnexal mass. A mass changes the
motion "dynamics" of the adnexae such that a
twisting of the adnexa becomes possible. This
mass can be a functional ovarian cyst, a dermoid, a
paratubal cyst, or any number of other benign or
malignant neoplasms. Once a complete torsion has
occurred, the arterial supply to the ovary is
occluded and necrosis can result. Patients with
adnexal torsion can present with a history of
intermittent pain that comes and goes as the
adnexa twists. The pain is usually severe and often
accompanied by episodes of nausea, vomiting, and
diaphoresis, as this patient had. They may need
narcotics to control the severe pain. A pelvic mass
will almost always be found on physical
examination or by ultrasound. If there is no adnexal
mass, the diagnosis of ovarian torsion is highly
unlikely. This is true because most normal ovaries
do not have the motion "dynamics" that will allow
them to twist.

Appendicitis (choice A) should always be a
consideration when a patient presents with right
lower quadrant pain. However, in this case, the
combination of the pain with the ovarian mass
makes ovarian torsion, and not appendicitis, the
most likely diagnosis.

Ectopic pregnancy (choice B) should also be an
important consideration when a young woman
presents with abdominal pain. Some emergency
departments have signs reading "Think Ectopic" to
keep staff aware of this possibility. In this case,
however, the patient is not pregnant (negative urine
hCG) which excludes ectopic from the differential.

Nephrolithiasis (choice C) can also cause
excruciating pain, as does ovarian torsion. With
nephrolithiasis, hematuria will often be present. In
this patient, the absence of hematuria and the
presence of the right adnexal mass make
nephrolithiasis less likely.

Pelvic inflammatory disease (choice E) is a
diagnosis that merits consideration in a woman with
abdominal pain with a negative hCG (it is far less
common during pregnancy). However, the ovarian
mass in this case makes torsion a more likely
diagnosis than PID.

A 77-year-old man becomes "senile" over a period of
3 or 4 weeks. He used to be active and managed all
of his financial affairs. Now, he stares at the wall,
barely talks, and sleeps most of the day. His
daughter recalls that he fell from a horse about a
week before the mental changes began. Which of
the following would a CT scan of his head most likely

A. Chronic epidural hematoma

B. Chronic subdural hematoma

C. Diffuse intracerebral bleeding

D. Frontal lobe infarction

E. Generalized, severe brain atrophy


The correct answer is B. People who are very old
or alcoholic have smaller brains in a skull that has
not changed in size; thus, very minimal trauma can
make the brain "rattle around" and tear a venous
sinus, from which a subdural hematoma very slowly
forms. Senility does not occur in a 3-week period.
Such marked changes in someone with recent
trauma should trigger a search for chronic subdural

Epidural hematomas (choice A) are typically acute,
from a tear of the middle meningeal artery following
trauma that fractures the skull.

Diffuse intracerebral bleeding (choice C) would
occur with very severe trauma and would give more
acute symptoms.

The frontal lobe (choice D) is responsible for
judgment and social graces, but not for financial
acumen and level of activity—the functions
that this man used to have and lost over a short
period of time.

Brain atrophy (choice E) is indeed present in the
very old or the alcoholic. That is what makes them
prone to develop chronic subdural hematomas. But,
brain atrophy alone would not explain the mental
changes that this man developed over a few

A fetus is delivered at 40 weeks' gestation. During
labor, the fetal heart monitor shows late
decelerations and loss of short- and long-term
variability. The membranes are ruptured to expedite
the delivery. The fluid is noted to contain meconium.
The infant is delivered 45 minutes later. At delivery,
the infant appears to be cyanotic and limp. He has
poor tone and deep reflexes. Moro's reflex is absent.
Ten hours later, he experiences a seizure. Which of
the following best explains this infant's perinatal

A. Encephalopathy from asphyxia

B. Inborn error of metabolism

C. Respiratory distress

D. Subarachnoid hemorrhage

E. Werdnig-Hoffman disease


The correct answer is A. Perinatal asphyxia
would explain the fetal heart tracings. The poor
tone and respiratory effort indicate the same.
Seizures would be expected several hours after
moderate hypoxia.

Inborn errors of metabolism (choice B) should not
complicate the pregnancy.

Respiratory distress (choice C) after a term
pregnancy is unlikely given adequate surfactant.

Subarachnoid hemorrhage (choice D) is
associated with no symptoms or with irritability that
resolves over days.

Infants with Werdnig-Hoffman syndrome (choice E)
have hypotonia but no encephalopathy.

A previously healthy 7-year-old girl comes to the
office with complaints of episodic abdominal pain
over the past several months. The pain is
periumbilical and sharp but does not wake her from
sleep or interfere with play. She has no fever, joint
complaints, or constipation or diarrhea. Growth and
development have been normal. The physical
examination is within normal limits. Which of the
following is the most likely diagnosis?

A. Acute appendicitis

B. Acute cholecystitis

C. Crohn disease

D. Functional abdominal pain

E. Irritable bowel syndrome


The correct answer is D. Functional abdominal
pain is pain that lasts for more than 3 months and
often interferes with normal activity. The pain is
periumbilical and often hard to describe. The pain
typically does not awaken patients from sleep or
interfere with pleasant activities. The pain is real
and is the result of the regulation of gastrointestinal
motility in response to either psychological or
physical stress.

Acute appendicitis (choice A) usually occurs with
right lower quadrant pain, fever, and anorexia. The
chronic nature described in the question would rule
out acute appendicitis.

Acute cholecystitis (choice B) presents with right
upper quadrant pain and vomiting, and again the
history of several months of symptoms would rule
out this diagnosis.

Crohn disease (choice C) would usually present
with abdominal pain, diarrhea (usually loose with
blood), and anorexia. Although the abdominal pain
lasts several months, such as in this case, it
usually causes weight loss and delayed growth.

Irritable bowel syndrome (choice E) would cause
abdominal pain that could last several months.
This condition would also typically cause bouts of
diarrhea alternating with constipation.

A 28-year-old woman with a history of paranoid
schizophrenia is brought by a friend to the hospital.
The woman had been an inpatient at a psychiatric
hospital; for several months after being discharged,
she had been maintained on haloperidol decanoate
shots. For the past couple of days, after the last
injection, she has appeared "strange." She is stiff,
cannot swallow or talk, and appears tremulous. The
friend is concerned that she has some kind of
infection, since she has a fever. On examination, her
temperature is 38.7 C (101.7 F), blood pressure is
157/104 mm Hg, pulse is 122/min, and respirations
are 24/min. She has increased tone in her neck and
extremities, and appears tremulous, diaphoretic, and
confused. Her leukocyte count is 19,600/mm3 and
the serum creatine phosphokinase is markedly
elevated. A workup for infection is negative. Which
of the following is the most likely diagnosis?

A. Acute dystonic reaction

B. Lethal catatonia

C. Malignant hyperthermia

D. Neuroleptic malignant syndrome

E. Serotonin syndrome


The correct answer is D. Neuroleptic malignant
syndrome (NMS) is a rare complication of
neuroleptic therapy that confers high mortality if not
recognized and treated promptly. It is defined by
the development of severe muscle rigidity and
elevated temperature in association with at least
two or more of the following: dysphagia, tremor,
diaphoresis, tachycardia, change in level of
consciousness, leucocytosis, elevated or labile
blood pressure, and elevated creatine
phosphokinase as an indicator of muscle injury.
The predisposing factors include high neuroleptic
doses, intramuscular injections, and lithium

Acute dystonic reaction (choice A) is one of the
extrapyramidal side effects experienced by 10% of
neuroleptic-treated patients within the first hours or
days of treatment. It typically lasts a couple of
hours and responds to anticholinergic drugs.

Lethal catatonia (choice B) is a syndrome
associated with major depressive disorder, mania,
mixed affective state, or schizophrenia. It requires
the presence of at least two of the following: motor
immobility, extreme motor activity, extreme
negativism, peculiar voluntary movement, echolalia,
or echopraxia. Autonomic instability or hyperthermia
can complicate it. Lethal catatonia can be a result
of a general medical condition when it does not
occur during the course of delirium or the
above-mentioned mental disorders.

Malignant hyperthermia (choice C) has several
features in common with NMS, such as muscle
rigidity, hyperthermia, and elevated creatine
phosphokinase, as well as a good response to
dantrolene. However, malignant hyperthermia is
induced by inhalant anesthetics, and the
susceptibility is inherited.

Serotonin syndrome (choice E) is generally the
result of an interaction between serotonergic
agents and monoamine oxidase inhibitors. It is
characterized by restlessness, myoclonus, changes
in mental status, diaphoresis, hyperreflexia, tremor,
and shivering.

A 63-year-old white male who has recently retired
from work as a plumber for over 30 years returns to
his family physician saying that he has been feeling
very down lately, and has been having decreased
appetite and a loss of interest in activities that used
to give him pleasure. He is a smoker, drinks no
alcohol, and is being treated by his family physician
for moderate essential hypertension. Which of the
following is the most appropriate next step in

A. Discuss activities that will help him enjoy
his retirement

B. Order a thyroid stimulating hormone level

C. Order electroconvulsive therapy (ECT)

D. Prescribe an antidepressant

E. Review the patient's medication


The correct answer is E. Many medications used
to control hypertension, such as propranolol, and in
the past, reserpine, are known to occasionally lead
to depressive symptoms. By evaluation of the
patient's medication record, the physician can
evaluate which medications were started at what
time and can make adjustments to dosage or
switching to alternative medications to control
hypertension. Changing the antihypertensive
medication will possibly improve the depressive
symptoms without the need to start an
antidepressant (choice D).

Choice A is an appropriate intervention, but it is
not the most appropriate next step, as the etiology
of the patient's depression may be overlooked.

Ordering a TSH level (choice B) is also
appropriate, as hypothyroidism can be an organic
cause of depression. However, given the patient's
medication history, evaluating possible
pharmacologic causes of depression takes
precedence in management of patient depression.

Electroconvulsive therapy (choice C) is indicated in
severe intractable depression when not
contraindicated by seizure disorder or other factors,
but is not indicated in this state.

Ocular examination is performed on a patient during
a routine medical check up. Retinal examination
demonstrates a generalized retinal arteriolar
constriction. The light reflex on the arterioles is broad
and dull. Two areas of flame-shaped hemorrhages
and multiple cotton wool spots are also seen. These
findings are most suggestive of which of the

A. Central retinal artery occlusion

B. Central retinal vein occlusion

C. Hypertensive retinopathy

D. Non-proliferative diabetic retinopathy

E. Proliferative diabetic retinopathy


The correct answer is C. The changes illustrated
are those of hypertensive retinopathy, and may
additionally include yellow hard exudates (due to
lipid deposition in the retina) and a congested and
edematous optic disk. Basically, what happens is
that the eye tries to protect itself from the
hypertension first with arteriolar constriction, and
then with time, thickening of the arteriolar walls
(producing the broad light reflex). The cotton wool
spots are actually small, superficial foci of retinal
ischemia, which occur when the arterioles squeeze
down too hard. The hemorrhage and deposits
occur because of vessel damage with leakage of
contents. Hypertensive retinopathy can be seen in
chronic essential hypertension, malignant
hypertension, and toxemia of pregnancy. Treatment
of the retinopathy is with control of the
hypertension. (Practically, progression can be
stopped and the hemorrhages will resolve, but the
vessel changes remain.)

Central retinal artery occlusion (choice A) usually
presents with sudden, unilateral blindness and
produces a pale opaque fundus with a red fovea.

Central retinal vein occlusion (choice B) can cause
painless visual loss and produces a congested and
edematous fundus with numerous hemorrhages.
The arteriolar changes of hypertensive retinopathy
are not present.

Nonproliferative diabetic retinopathy (choice D)
also causes hemorrhage and exudates in the retina,
but additionally has distinctive microaneurysms
(visible as red dots).

Proliferative diabetic retinopathy (choice E) has the
changes of nonproliferative diabetic retinopathy
with the addition of neovascularization with vessel
growth into the vitreous.

A 57-year-old woman presents to her physician for
follow-up of a fasting serum cholesterol level of 236
mg/dL. She is post-menopausal since age 52, and
has been not been on hormone replacement
therapy. She has a positive family history for
coronary artery disease and she has smoked
one-half pack of cigarettes per day for the past 20
years. During her last physical examination, a lipid
profile was ordered, and she presents today for
evaluation of those results. Which of the following
lipid panels would most strongly suggest the need
for pharmacologic therapy in this patient?

A. Total cholesterol 180 mg/dL, LDL
cholesterol 140 mg/dL

B. Total cholesterol 184 mg/dL, LDL
cholesterol 100 mg/dL

C. Total cholesterol 230 mg/dL, LDL
cholesterol 100 mg/dL

D. Total cholesterol 245 mg/dL, LDL
cholesterol 165 mg/dL

E. Total cholesterol 285 mg/dL, LDL
cholesterol 100 mg/dL


The correct answer is D. For those patients in
whom a fasting panel has been obtained, a
stepwise approach to intervention based on the
patient's LDL and risk factors may be used. A
patient with 2+ risk factors (this patient) and an
LDL of greater than 160 mg/dL warrants medical

A total cholesterol of 180 mg/dL, LDL cholesterol of
140 mg/dL (choice A) or a total cholesterol of 184
mg/dL with an LDL cholesterol 100 mg/dL (choice
B) in this patient could be managed with a trial of
dietary modification and education.

For marginally high total cholesterol: total
cholesterol 230 mg/dL, LDL cholesterol 100 mg/dL
(choice C), there is no indication for drug therapy
because the LDL is still not above 130.

A total cholesterol of 285 mg/dL with an LDL
cholesterol of 100 mg/dL (choice E), although
disconcerting, does not require drug therapy. The
total cholesterol is elevated, but the LDL is not,
suggesting either increased triglycerides or an
equally high HDL level.

A 14-year-old girl comes to the physician for an
annual examination. She has no complaints. She
became sexually active during the past year and
uses condoms occasionally for contraception. She
has asthma, for which she occasionally takes an
albuterol inhaler. She had an appendectomy at age
9. Physical examination is unremarkable including a
normal pelvic examination. When should this patient
begin having Pap testing?

A. Immediately

B. Age 16

C. Age 18

D. Age 20

E. Age 21


The correct answer is A. Pap testing is used to
screen women for cervical cancer. The
development of cervical cancer is believed to be a
gradual process in which the cervical cells
gradually progress from dysplasia to carcinoma in
situ to invasive cancer. Cervical cancer is certainly
linked to sexual activity, as the human

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