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Posted by baba from IP on November 08, 2014 at 07:08:13:

A 19-year-old female comes to the physician because of left lower quadrant pain for 2 months. She states that she first noticed the pain 2 months ago but now it seems to be growing worse. She has had no
changes in bowel or bladder function. She has no fevers or chills and no nausea, vomiting, or diarrhea. The pain is intermittent and sometimes feels like a dull pressure. Pelvic examination is significant for a left
adnexal mass that is mildly tender. Urine hCG is negative. Pelvic ultrasound shows a 6 cm complex left adnexal mass with features consistent with a benign cystic teratoma (dermoid). Which of the following is the
most appropriate next step in management?
A. Repeat pelvic examination in 1 year
B. Repeat pelvic ultrasound in 6 weeks
C. Prescribe the oral contraceptive pill
D. Perform hysteroscopy
E. Perform laparotomy

Explanation: The correct answer is E. This patient has a presentation and findings that are most consistent with a benign cystic teratoma (dermoid). Dermoids are a type of ovarian germ cell tumor. Germ cell
tumors are the most common type of ovarian neoplasm in females under the age of 20 and dermoids are the most common benign ovarian neoplasm. Dermoids can range in size from small masses that are noted
incidentally on ultrasound and cause no symptoms, to large cysts that cause pain and pressure, as this patient has. Laparotomy is the most appropriate next step in the management of this patient because, as
adnexal masses enlarge--especially when they become greater than 5 cm--the risk of ovarian torsion increases. Thus, laparotomy with removal of the dermoid is indicated to prevent torsion. Also, this patient's
mass is causing her symptoms of pain and pressure and, on that basis, should be removed. Finally, while the mass most likely is a dermoid, this is not certain without pathologic diagnosis and, therefore, the cyst
should be removed and evaluated by a pathologist. At the time of surgery, close examination should be made of the other ovary because dermoids may be found bilaterally in more than 10% of cases. To repeat
pelvic examination in 1 year (choice A) would not be correct management. This patient is symptomatic with a 6 cm ovarian mass that is at risk for torsion. She should, therefore, be managed surgically. To repeat
pelvic ultrasound in 6 weeks choice B) is appropriate for some adnexal masses. For example, in a young woman with a small complex cyst that appears consistent with a corpus luteum, it may be most prudent to
recheck an ultrasound in 6 weeks to see if the cyst has resolved. This patient, however, is symptomatic with a 6 cm cyst that appears to be a dermoid, which will not resolve spontaneously. She, therefore, requires
surgery. To prescribe the oral contraceptive pill (choice C) may help to prevent future ovarian cysts but it will not resolve this cyst, which requires surgical management. To perform hysteroscopy (choice D) would
not be indicated. Hysteroscopy is used to evaluate the uterine cavity and would not be used for management of an adnexal mass.

A 27-year-old man sustained penetrating injuries of the chest and abdomen when he was repeatedly stabbed with a long ice-pick. At the time of admission, he had a right pneumothorax, for which a chest tube
was placed prior to undergoing a general anesthetic for exploratory laparotomy. The operation revealed no intraabdominal injuries and was terminated sooner than had been anticipated. The patient remained
intubated, waiting for the anesthetic to wear off. Because he was not moving enough air, he was placed on a respirator. Then, he suddenly went into cardiac arrest and died. All through this time he had been
hemodynamically stable, and never had any signs of hypotension or arrhythmias. Which of the following was the most likely cause of the cardiac arrest?
A. Air embolism
B. Fat embolism
C. Myocardial infarction
D. Pulmonary embolus
E. Tension pneumothorax

Explanation: The correct answer is A. Truly sudden death, with no warnings whatsoever, brings to mind the possibility of air embolism. The mechanism in this case is suggested by the circumstances. The patient
had deep penetrating injuries that may have involved a major vein and an adjacent bronchus. When he was placed on the respirator, the air was forced through from the tracheobronchial tree into the vein, and
thus into the heart. Fat embolism (choice B) is seen with multiple long bone fractures, and the symptomatology is respiratory failure. Myocardial infarction (choice C) would be extremely unlikely in a young man
who was never hypotensive, and never showed arrhythmias. Pulmonary embolus (choice D) is seen late in the postoperative period after several days of reduced mobility. This man would have had no opportunity
to develop clots in major veins in such short clinical course. Tension pneumothorax (choice E) would be unlikely to develop with a chest tube in place. However, even if we assume the tube was clogged or kinked
and thus not functioning properly, a tension pneumothorax does not cause sudden death: it causes progressive hemodynamic shock and respiratory distress.

A 14-year-old male presents with a complaint of soreness, and weakness in his legs for the past day that has slowly spread from his calves to his thighs. He now complains of weakness in his trunk and arms. On
examination he appears tired and lays on the examining table. His temperature is 37 C (98.6 F), pulse is 48/min, and respirations are 22/min. Both of his legs are diffusely tender. Deep tendon reflexes are absent
in the lower extremities, and sensation is greatly diminished. Which of the following studies is essential for this patient's diagnosis? Top of Form 1
A. Creatinine phosphokinase levels
B. Stool culture for Campylobacter jejuni
C. Motor nerve conduction test
D. Cerebrospinal fluid studies
E. Muscle biopsy
Bottom of Form 1
Explanation: The correct answer is B. Guillain-Barré syndrome (GBS) is a postinfectious polyneuropathy that causes demyelination of BOTH motor and occasionally, sensory nerves. It is classically an ascending
paralysis. CSF studies are essential for diagnosis and reveal a protein level usually twice normal values but with normal amounts of white blood cells, normal glucose level and an absence of pleocytosis (elevated
lymphocytes). Autonomic nervous system involvement can produce the bradycardia seen in this vignette. Creatinine phosphokinase levels (choice A) may be mildly elevated and sometimes are normal, but are not
essential for diagnosis. Motor nerve conduction tests (choice C) would show decreased velocities, but are not specific for GBS. A muscle biopsy (choice D) is not indicated and can be normal in early stages. Late
disease reveals denervation atrophy. Stool culture for Campylobacter jejuni(choice E), a well recognized infection associated with GBS, is again not essential for diagnosis. By the time the disease presents stool
cultures are often negative.

A 43-year-old man reports that he had a 9-lb. weight loss over the past 9 months. The symptoms are accompanied by difficulty swallowing both solids and liquids during that time. He has woken on several
occasions at approximately 4 AM and regurgitated partially digested dinner contents. An upper gastrointestinal series is performed and reveals a widely dilated esophagus with a smoothly tapering distal
esophagus. There appears to be partially digested food present in the esophagus. Which of the following is the most likely cause of this patient's symptoms? Top of Form 1
A. Achalasia
B. Diffuse esophageal spasm
C. Esophageal squamous cancer
D. Peptic stricture
E. Scleroderma
Bottom of Form 1
Explanation: The correct answer is A. This patient has the symptoms of a motility-type dysphagia in that he has difficulty with most solids, not liquids, from the onset of his symptoms. The nocturnal aspiration of
food occurs because the esophagus remains filled for hours or even days after completing a meal. The x-ray film reveals the typical dilated esophagus of achalasia, which is termed a bird's-beak esophagus, with
distal esophageal tapering. Diffuse esophageal spasm (choice B) will typically produce "non-cardiac chest pain" in association with a motility-type dysphagia. Esophageal squamous cancer (choice C) would
produce a mechanical type dysphagia and is unlikely in a 42-year-old man without any specific risk factors, i.e. smoking, drinking, lye ingestion, or Plummer-Vinson syndrome. Peptic stricture (choice D) is wrong
because it would produce a mechanical, not a motility, type dysphagia. Scleroderma (choice E) will also produce a motility-type dysphagia, but it is very uncommon for men to develop this disease. Furthermore
aspiration in scleroderma occurs only after a peptic stricture has developed. Prior to this, the lower esophageal sphincter is wide open, and foods do not accumulate in the esophagus.

A 15-year-old girl is brought to the pediatrician's office because of sudden deterioration of school performance. Over the past month, her mother has noticed an occasional paint stain on the girl's hands. Her
mother also noticed six bottles of typewriter correction fluid in her bedroom about a week ago. She raised the concern of inhalant abuse. Which of the following is the most likely consequence of chronic inhalant
abuse? Top of Form 1
A. Arrhythmia
B. Bronchial asthma
C. Cerebral hemorrhage
D. Encephalopathy
E. Respiratory depression
Bottom of Form 1
Explanation: The correct answer is D. Inhalant abuse is the intentional inhalation of volatile hydrocarbons, such as model glue, correction fluid, spray paint, and gasoline, to achieve an altered mental state. It is a
common health problem in adolescence. The effect of inhaling a large quantity of hydrocarbons has been described as "quick drunk" because it resembles alcoholic intoxication. Initially, euphoria develops; then,
lightheadedness and agitation. Disorientation, ataxia, and dizziness might develop with increasing intoxication. In extreme cases, generalized weakness, hallucinations, and nystagmus can occur. Abusers often
show deterioration in school performance, disturbance of family relationships, and increased risk-taking behaviors. Encephalopathy is the major chronic morbidity following chronic inhalant abuse. Hydrocarbons
are highly lipophilic and can easily distribute to the brain. Studies have shown that chronic abusers have radiographic evidence of CNS damage, such as loss of brain mass on CT and white matter degeneration on
MRI. Clinically, chronic abusers often have cognitive and cerebellar dysfunction, including peripheral and cranial neuropathy, visual loss, and parkinsonism. Inhalant abuse poses a significant health threat to
teenagers. Surveys have shown that about 15% to 20% of high school seniors have used inhalants in the past. These figures, however, likely underestimate the true prevalence because of under-reporting and
school dropouts. A high level of suspicion is needed to diagnose inhalant abuse. A good history is essential because there is no drug screen test that can detect inhalant hydrocarbons.

A 39-year-old businessman with no prior medical problems is rushed to the emergency department following the sudden onset of dizziness, shortness of breath, and palpitations. His blood pressure on
admission is 190/110 mm Hg, his pulse is 124/min, and he is diaphoretic. His wife says that his behavior has changed over the past couple month since he became CEO of his company. He has become moody. At
times, he seems energetic, euphoric, or irritable; then he seems "to be down" for no reason. He just returned from one of many business meetings and again spent more money than ever before. The patient is
smiling inappropriately and denies any alcohol or drug abuse. Which of the following will most likely be found on a urine drug screen? Top of Form 1
A. Cocaine
B. Heroin
C. Nicotine
D. Organic inhalants
E. Phencyclidine
Bottom of Form 1
Explanation: The correct answer is A. Cocaine intoxication is characterized by sympathic stimulation, including tachycardia, hypertension, and sweating. The mood is elated and euphoric while intoxicated, and
there is restlessness and pressured speech. Psychotic symptoms can occur with prolonged use. Heroin intoxication (choice B) causes significant behavioral changes and impaired social functioning, as well as
pupillary constriction, drowsiness, slurred speech, and impairment of attention and memory. Signs of nicotine intoxication (choice C) are nausea, vomiting, salivation, pallor, weakness, abdominal pain, diarrhea,
dizziness, headache, tremor, cold sweats, tachycardia, confusion, and sensory disturbances. Organic inhalant intoxication (choice D) causes dizziness, nystagmus, incoordination, lethargy, unsteady gait, slurred
speech, muscle weakness, tremor, blurred vision, psychomotor retardation, and stupor. Phencyclidine intoxication (choice E) causes behavioral changes shortly after the use of drug, as well as two or more of the
following signs: ataxia, nystagmus, hypertension, tachycardia, dysarthria, muscle rigidity, numbness, seizures, or coma.

A 23-year-old woman calls her physician for the results of her Pap test. She has a history of Chlamydia. She has never had an abnormal Pap. She occasionally has unprotected intercourse. The physician informs
her that the Pap was normal. The patient is relieved, but wants to know whether this result could be wrong. The physician explains that a Pap test detects abnormal cells in roughly 4 of every 5 women who have
abnormal cervical cells. Which of the following represents the sensitivity of the Papanicolaou test? Top of Form 1
A. 0%
B. 1%
C. 20%
D. 80%
E. 100%
Bottom of Form 1
Explanation: The correct answer is D. The Pap test is an excellent method of screening for cervical cancer. It has a relatively low-cost and is noninvasive and effective. Use of the Pap for screening over the past 50
years has resulted in a 70% decrease in the mortality from cervical cancer. However, the test is not without its flaws. The primary drawback of the test is its high false-negative rate. In the case of the Pap, a false-
negative is a woman who has abnormal cervical cells but is declared to have a normal Pap smear. These false-negative results can be caused by any of the steps in the process, including errors in sampling,
preparation, screening, and interpretation. The larger the number of false-negative results, the lower is the sensitivity of a test. Sensitivity of a test is calculated by dividing the number of patients who have the
disease and test positive for the disease by the total number of patients that have the disease. In the above example, four women who have abnormal cervical cells will test positive for abnormal cervical cells. This
number (4) should then be divided by the total number of women with truly abnormal cells (5). This gives a result of 4/5 or 0.8 or 80%. To state that the sensitivity of the Pap test is 0% (choice A) or 1% (choice B) is
incorrect. If this were the case, it would mean that the Pap test would correctly identify none or only 1 of every 100 women with truly abnormal cervical cytology. This would make the Pap test a very poor or
completely meaningless screening test. A screening test that is 20% (choice C) sensitive is also a very poor screening test. A screening test should ideally have high sensitivity and specificity. A test that is has only
20% sensitivity would identify only 20 of every 100 women with a given disease. This would make it a very poor screening test. A screening test that has 100% (choice E) sensitivity for a disease would be ideal. If
the Pap test were 100% sensitive, it would mean that every woman with abnormal cervical cells would be correctly identified. However, this is not the case because of the possible errors that were described above.
Also, efforts to increase the sensitivity of a screening test often lead to a loss of specificity and an increases in the percentage of false positives.

On the 5th postoperative day after abdominal surgery, a patient has been draining copious amounts of clear pink fluid from his midline laparotomy wound. A medical student removes the dressing, confirms that it
is soaked, and sees a normal-appearing fresh wound with a row of skin staples in place. The student asks the patient to sit up so he can get out of bed and be helped to the treatment room for a more thorough
examination. When the patient complies, the wound opens widely, and a handful of small bowel suddenly rushes out. Which of the following is the most appropriate management at this time? Top of Form 1
A. Cover the bowel with dry sterile dressings and schedule urgent surgical closure
B. Cover the bowel with sterile dressings soaked in warm saline and rush the patient to the operating room
C. Irrigate the bowel with cold antiseptic solutions while awaiting urgent surgical closure
D. Take the patient to the treatment room and suture the skin edges together
E. Wearing sterile gloves, push the bowel back in and tape the wound securely
Bottom of Form 1
Explanation: The correct answer is B. Until the patient attempted to get out of bed, he had a wound dehiscence that could have been handled by taping the wound securely. Once the bowel came out, the problem
became an evisceration. Immediate surgical repair is mandatory. While setting it up, the bowel must be protected from drying out, and the patient must be protected from significant heat loss. Thus, the key is
warm and moist dressings. Dry dressings (choice A) would prevent further contamination but would fail in the key elements of "warm and moist." Cold antiseptic solutions (choice C) would irritate the bowel and
contribute to hypothermia. Once an evisceration has occurred, the entire abdominal wall has to be surgically closed. Suturing the skin edges in an inadequate facility (choice D) or resorting to tape (choice E) would
not suffice.

A 33-year-old female with bipolar disorder and history of alcohol and drug abuse presents to the emergency department after being found down at home. She was found unresponsive to voice and touch, with 16
empty packets of medication next to her, each containing 50 mg of diphenhydramine. There was also an empty bottle of acetaminophen and a half-empty whiskey bottle near her bed. A suicide note was present
on a nearby table. In the field, her temperature was 36 C (96.8 F), blood pressure was 90/55 mm Hg, her pulse was 140 and regular, and her respirations were 8/min. Additional data obtained in the field included
a finger stick glucose of 20 mg/dL and an oxygen saturation of 87% on room air. Of the data available in the field, which of the following findings is most immediately threatening to her outcome? Top of Form 1
A. Blood pressure of 90/55
B. Finger stick glucose of 20 mg/dL
C. Oxygen saturation of 87% on room air
D. Pulse of 140
E. Respirations of 8
Bottom of Form 1
Explanation: The correct answer is B. When the blood glucose level drops below approximately 25 mg/dL, as in this case, cerebral glucose reserves are quickly depleted. In response, protein and lipid components
of neurons are metabolized, which can lead to irreversible brain damage. Therefore, prompt treatment with intravenous glucose is critical in this patient's initial management. While the blood pressure of 90/55 is
relatively low (choice A), it should be well tolerated by the young woman in this case. However, older patients with significant vascular disease who are accustomed to higher blood pressures may not tolerate this
blood pressure. Even though the oxyhemoglobin desaturation curve is relatively flat at the upper end of the saturation scale, an oxygen saturation of 87% (choice C), while not optimal, is consistent with life and
should not pose any damage to vital tissues in the short term. A pulse of 140 (choice D) is immediately threatening to life only if the heart rhythm is at risk to degenerate into a dangerous rhythm or if the patient
is unable to maintain a reasonable blood pressure with the tachycardic pulse. This is rarely the case with a sinus tachycardia (as evidenced by the fact that most people exercising are not unstable due to
tachycardia). The relatively slow respiration rate of 8 (choice E) likely reflects the metabolic and toxic state of the patient, and is threatening to the patient only if it limits oxygenation, ventilation, or acid/base

A 64-year-old woman initiates chemotherapy for metastatic breast cancer. She develops severe nausea followed by hours of vomiting during her first chemotherapy infusion, which becomes worse on subsequent
infusions. Which of the following would be most effective in controlling her vomiting? Top of Form 1
A. Bismuth
B. Morphine
C. Omeprazole
D. Ondansetron
E. Sertraline
Bottom of Form 1
Explanation: The correct answer is D. Severe nausea and vomiting can accompany many forms of chemotherapy, and many patients experience these side effects as the worst problem related to their treatment.
Many agents used to control nausea and vomiting in other settings are nearly useless for the very severe nausea and vomiting that accompanies chemotherapy. It has been postulated that the severe nausea is
related to release of neurotransmitters by damaged enterochromaffin (neuroendocrine) cells in the small intestine. Ondansetron, which is available in both IV and oral forms, is the most effective agent for emesis
induced by chemotherapy. This drug is a selective inhibitor of one type of the 5-hydroxytryptamine (synonym serotonin) receptor, which is present both peripherally on vagal nerves and centrally in the
chemoreceptor trigger zone of the area postrema of the brain. Bismuth (choice A) preparations can be used to control diarrhea and mild nausea of the vertigo/motion sickness type, but are nearly useless with
chemotherapy-induced vomiting. Morphine (choice B) is commonly given to cancer patients to control pain symptoms but actually increases vomiting by stimulating the chemoreceptor trigger zone. Omeprazole
(choice C) reduces acid secretion but does not affect chemotherapy-induced vomiting. It is used as a component of an anti-Helicobacter regimen. Sertraline (choice E) is an antidepressant of the selective serotonin
reuptake inhibitor (SSRI) family..

A 65-year-old woman presents with slowly progressive dementia and visual hallucinations. Mental status examination reveals severe deficits in attention, visuospatial skills, and verbal fluency, while short-term
memory is only mildly impaired. Physical examination shows rigidity of arms and Parkinson-like extrapyramidal signs. An MRI of the head demonstrates mild diffuse cortical atrophy. Which of the following is the
most likely diagnosis? Top of Form 1
A. Alzheimer-type dementia
B. Creutzfeldt-Jacob disease
C. Dementia with Lewy bodies
D. Dementia associated with motor neuron disease
E. Pick dementia

Bottom of Form 1
Explanation: The correct answer is C. The association of dementia with visual hallucinations and extrapyramidal signs is highly characteristic of a type of dementing disorder variably referred to as diffuse Lewy
body disease or dementia with Lewy bodies. This condition has been identified as a well-defined entity in recent times (early 80s). At first considered a rare condition, it is now recognized as one of the most
frequent dementing disorders, second in incidence only to Alzheimer disease in most hospital-based epidemiological studies. The morphologic substrate consists of intraneuronal inclusions identical to the Lewy
bodies in the substantia nigra of Parkinson patients. Dementia with Lewy bodies affects the substantia nigra (thus explaining the extrapyramidal symptoms), various neocortical fields (especially the cingulate
gyrus), and subcortical nuclei, including the basal nucleus of Meynert and amygdala. Another feature of this condition is its fluctuating clinical course, with alternating periods of improvement and deterioration.
Alzheimer-type dementia (choice A) is characterized by slowly progressive intellectual loss that predominantly affects short-term memory. Neither visual hallucinations nor extrapyramidal manifestations are part
of the clinical picture of Alzheimer disease. Creutzfeldt-Jacob disease (CJD) (choice B) is caused by an aberrant form of prion protein (PrP). Dementia, mental status changes and myoclonus are characteristic of
CJD, as well as a rapidly progressive course leading to death within 6-12 months. Dementia associated with motor neuron disease (choice D) is infrequent. Dementia develops in one tenth of patients with motor
neuron disease. Memory deficits are similar to those seen in Alzheimer disease. Pick dementia (choice E) is a rare form of dementia, predominantly affecting presenile (i.e., younger than 65) patients. It is
characterized by striking atrophy of the frontal and anterior temporal lobes. Clinically, disinhibition and personality changes constitute the most peculiar manifestations.

A patient presents to a psychiatrist for depressive symptoms. He talks about his past psychiatric problems. He also mentions he is an alcoholic and has been taking disulfiram for some time to keep sober. He once
tried to drink after taking the drug and ended up being terribly sick. Which of the following principles best describes this treatment of alcoholism? Top of Form 1
A. Conditioned avoidance
B. Extinction
C. Flooding
D. Positive reinforcement
E. Reciprocal inhibition
Bottom of Form 1
Explanation: The correct answer is A. Conditioned avoidance is a term that describes the pairing of an unpleasant stimulus with the stimulus that causes maladaptive behavior. Extinction (choice B) requires the
removal of the reward for inappropriate behavior so that maladaptive behavior decreases. It is often used in child psychiatry with patients who have behavioral problems. Flooding (choice C) is a therapeutic
technique in which a patient is exposed to the feared situation without the possibility to escape. This experience is stressful and it must be done in a supervised and controlled manner. Positive reinforcement
(choice D) happens when a subject is rewarded for manifesting desired behavior. Reciprocal inhibition (choice E) happens when a response that is antagonistic to the undesired behavior is paired with the
behavioral response (e.g., relaxing along with anxiety provoking stimuli).

A 49-year-old waitress presents with painful swelling of the left knee. The symptoms began over the past 48 hours and have limited her ability to work. She has developed a fever over the past 24 hours but
denies rigors, cough, rash, or headaches. On physical examination, her temperature is 38.3 C (100.9 F), blood pressure is 116/72 mm Hg, pulse is 96/min, and respirations are 16/min. There is a palpable
effusion around the left knee capsule in association with erythema and warmth. Which of the following would be the most appropriate next step in management? Top of Form 1
A. Complete blood count
B. Left knee x-ray film
C. Left knee arthrocentesis
D. Left knee MRI
E. Left knee arthroscopy

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