ANSWER: A (Note: An article on this subject appeared in AFP after the exam was sent to the
printer, and came to our attention after the exam was scored. B is now considered a
better answer, and the critique and references have been updated to reflect this.)
This patient's symptoms are consistent with irritable bowel syndrome (IBS). Her history, physical
examination, and laboratory evaluation did not show any evidence of peptic ulcer disease, celiac disease,
thyroid disease, or inflammatory bowel disease. Red flags include unintentional and unexplained weight
loss, rectal bleeding, a family history of bowel or ovarian cancer, and a change in bowel habits to looser
and/or more frequent stools persisting for more than 6 weeks in a person over 60. The patient does not
have any of these findings and therefore does not require any additional testing to confirm the diagnosis
Patients should be given information that explains the importance of self-help in effectively managing their
IBS. This should include information on general lifestyle, physical activity, and dietary intake. A Cochrane
review showed that soluble fiber such as psyllium is not effective for IBS. Lubiprostone is effective for
Most cases of uncomplicated acute pyelonephritis, including the one described here, can be managed in
the outpatient setting. Findings that might prompt consideration of inpatient management include comorbid
conditions (e.g., renal dysfunction, urologic disorders, diabetes mellitus, advanced liver or cardiac
disease), hemodynamic instability, male sex, metabolic derangements, pregnancy, severe pain, a toxic
appearance, an inability to take liquids by mouth, or a temperature >39.4°C (103.0°F).
Nitrofurantoin for 5 days is an appropriate treatment for an uncomplicated urinary tract infection, but not
for pyelonephritis. Amoxicillin is generally not considered first-line treatment for pyelonephritis because
of a high prevalence of resistance to oral -lactam antibiotics, and it should only be chosen if susceptibility
results for the urinary isolate are known and indicate likely activity. Fluoroquinolones, such as
ciprofloxacin, are the preferred empiric antibiotic treatment for outpatient treatment of pyelonephritis, as
long as the local prevalence of resistance to community-acquired Escherichia coli is less than 10%.
A 34-year-old white female who works as an engineer for a major corporation complains of
fatigue, low energy, and a depressed mood. She states that she has felt this way for most of her
life. She feels depressed most of the time but denies any recent stresses or significant losses in
her life. She reports that she is doing well at work and that she recently received a promotion.
She has no interests other than her job and states that she has no happy thoughts and that her
self-esteem is very low. She denies suicidal thoughts but states that she does not care if she dies.
She has had no sleep disturbance, change in appetite, or difficulty concentrating. She is taking
no medications and denies substance abuse. Results of a recent medical evaluation required by
her employer were all normal, including a physical examination, EKG, multiple chemical
profile, CBC, urinalysis, and TSH level.
Which one of the following is the most likely diagnosis?
A) Major depression
B) Dysthymic disorder
C) Bipolar disorder
E) Adjustment disorder with depressed mood
Dysthymic disorder is characterized by depressed mood for at least 2 years in addition to at least two of
the following: change in appetite, alteration in sleep, low energy, low self-esteem, poor concentration,
or feelings of hopelessness. There must be no history of a manic or hypomanic episode, substance abuse,
a chronic psychotic disorder, or an organic cause.
Symptoms of major depression are similar to those of dysthymia and can occasionally be difficult to
distinguish from dysthymia. This patient's lifelong history of a depressed mood not triggered by any
particular depressing event, and the predominance of patient complaints as opposed to objective signs,
indicate that major depression is not the diagnosis in this case. Bipolar disorder is characterized by major depression with periods of mania. Cyclothymia is characterized
by dysthymia with periods of hypomania. Adjustment disorder with depressed mood is characterized by
impaired social or occupational functioning or abnormal symptoms within 3 months of a stressor.
This patient has the classic pulmonary manifestations of Ascaris infection, which develop during the
transpulmonary passage of Ascaris larvae (SOR C). The larvae produce a syndrome of transient
eosinophilic pulmonary infiltrates, commonly referred to as Löffler syndrome. Ascaris infection is the most
common worldwide cause of this syndrome. Symptoms develop when larvae are within the lungs,
approximately 9-12 days after ingestion of Ascaris eggs. Patients may develop the following symptoms
• an irritating, nonproductive cough and burning substernal discomfort
• dyspnea and blood-tinged sputum
• urticaria during the first few days of the illness (15% of patients)
• fever, which infrequently exceeds 38.3°C (101.0°F)
• crackles and wheezing, with no signs of consolidation
The acute symptoms generally subside within 5-10 days, depending upon the severity of the illness. The
chest radiograph may show round or oval infiltrates ranging in size from several millimeters to several
centimeters in both lung fields; these lesions are more likely to be present when blood eosinophilia exceeds
10%. The infiltrates are migratory and may become confluent in perihilar areas, and usually clear
completely after several weeks.
Taenia does not infiltrate the lungs, but forms cysts in the muscles. Diphyllobothrium latum, the fish
tapeworm, does not cause pulmonary problems. Enterobius (pinworm) does not migrate from the
gastrointestinal tract into other organs.
A 50-year-old male presents to your office with erythroderma and fever. He has not had a sore
throat, rhinorrhea, cough, or urinary tract symptoms. His current medications include lisinopril
(Prinivil, Zestril), atenolol (Tenormin), and allopurinol (Zyloprim). On examination he has a
blood pressure of 110/90 mm Hg, a pulse rate of 90 beats/min, and a temperature of 38.6°C
(101.5°F). The skin is remarkable for marked erythema over 90% of the body, with tenderness
to touch. His mental status is clear and his neck is supple. Mildly tender adenopathy is noted in
the neck, axillae, and groin. He has no oral ulcerations or ocular symptoms.
A CBC shows a WBC count of 15,000/mm3 (N 4300-10,800) with 20% eosinophils. A
metabolic profile shows an AST (SGOT) level of 100 U/L (N 10-40) and an ALT (SGPT) level
of 110 U/L (N 10-55), but is otherwise normal.
Which one of the following is the most likely diagnosis?
A) Stevens-Johnson syndrome
C) Red man syndrome
D) Toxic shock syndrome
E) Drug reaction with eosinophilia and systemic symptoms (DRESS syndrome)
DRESS is an acronym for Drug Reaction with Eosinophilia and Systemic Symptoms. The hallmark of
DRESS syndrome is erythroderma accompanied by fever, lymphadenopathy, elevation of liver enzymes,
and eosinophilia. The offending medication should be discontinued immediately and treatment with
corticosteroids should be initiated. Seizure medications such as carbamazepine, phenytoin, lamotrigine,
and phenobarbital are responsible for approximately one-third of cases. Allopurinol-associated DRESS
syndrome has the highest mortality rate. Toxic shock syndrome should be suspected in patients with erythroderma, hypotension, and laboratory
evidence of end-organ involvement (elevated liver enzymes or kidney function studies, anemia,
thrombocytopenia, or elevation of creatine kinase). Treatment with intravenous clindamycin, which inhibits
toxin synthesis, should be undertaken immediately.
Stevens-Johnson syndrome is characterized by a vesiculobullous rash with mucocutaneous involvement,
and erysipelas is a painful localized rash with well-demarcated borders. Red man syndrome is associated
This lesion is suspicious for melanoma, based on the asymmetry, irregular border, color variegation, and
size larger than 6 mm. In addition, a history of evolution of the lesion, with changes in size, shape, or
color, has been shown in some studies to be the most specific clinical finding for melanoma. The preferred
method of biopsy for any lesion suspicious for melanoma is complete elliptical excision with a small
margin of normal-appearing skin. The depth of the lesion is crucial to staging and prognosis, so shave
biopsies are inadequate. A punch biopsy of the most suspicious-appearing area is appropriate if the location
or size of the lesion makes full excision inappropriate or impractical, but a single punch biopsy is unlikely
to capture the entire malignant portion in larger lesions. Electrodesiccation and curettage is not an
appropriate treatment for melanoma. Mohs surgery is sometimes used to treat melanomas, but is not used
for the initial diagnosis.
Most episodes of pharyngitis are caused by viral rather than bacterial infections. The use of clinical
decision rules for diagnosing group A -hemolytic streptococcal pharyngitis improves quality of care while
reducing unwarranted treatment and overall cost (SOR A). The original Centor score used four signs and
symptoms to estimate the probability of acute streptococcal pharyngitis in adults with a sore throat, and
was later modified by adding age as a fifth criterion. One point each is assigned for (1) absence of cough,
(2) swollen, tender anterior cervical nodes, (3) temperature >38.0°C (100.4°F), and (4) a tonsillar
exudate and swelling. One point is added for patients between the ages of 3 and 14 years, and a point is
subtracted for patients over the age of 45. The cumulative score determines the likelihood of streptococcal
pharyngitis and the need for antibiotics, and guides testing strategies. Patients with a score of zero or 1 are
at very low risk for streptococcal pharyngitis and do not require testing or antibiotic therapy. Patients with
a score of 2-3 should be tested using a rapid antigen test or throat culture, and a positive result warrants
antibiotic therapy. Patients with a score of 4 or higher are at high risk for streptococcal pharyngitis, and
empiric treatment may be considered. This patient's score is zero, and no testing or treatment is warranted.
Slipped capital femoral epiphysis is often misdiagnosed, as the symptoms are frequently vague. It is the
most common hip disorder in adolescents, with the age range being 9 to 15 years. It occurs when the
proximal femoral epiphysis slips posteriorly and inferiorly on the femoral neck through the growth plate.
The typical presentation is a limping child who may have pain in the groin, hip, thigh, or knee. Very often
the pain is vague and poorly localized. It occurs more often in boys, with African-Americans and Pacific
Islanders having a higher rate of involvement, possibly due to increased levels of obesity in these
Physical findings vary, depending on the severity of the slippage. A child with a severe slip may not be
able to bear weight. Obligatory external rotation of the involved hip is noted when the hip is passively
flexed to 90°. Radiographs are needed to diagnose unstable slipped capital epiphysis, and should include
frog-leg lateral views and anteroposterior views of both hips.
Another cause of hip pain in adolescent patients is apophyseal avulsion fractures. Clinical features include
pain after a sudden, forceful movement. Hip apophysitis presents as activity-related hip pain with a history
of overuse and negative radiographs. In children under the age of 10 years, transient synovitis is also a
common cause of hip pain. It occurs after a viral illness and is associated with negative radiographs but
positive laboratory tests. Fractures may be seen in children on occasion, but there will be a history of
trauma. Septic arthritis is an infrequent cause of hip pain in children, but patients have a history of fever
with elevation of the WBC count and inflammatory joints. The diagnosis would be confirmed by joint
aspiration. Legg-Calvé-Perthes disease is also infrequent, and features include vague hip pain with
decreased internal rotation of the hip. The diagnosis is based on findings from radiographs or MRI.
The American College of Cardiology Foundation/American Heart Association guidelines for early
cardiovascular assessment do not recommend lipoprotein and apolipoprotein levels. A C-reactive protein
level can help to determine the need for statin therapy in men 50 and older and women 60 and older whose
LDL-cholesterol levels are <130 mg/dL and who are not on lipid-lowering medication, hormone therapy,
or immunosuppressive therapy, and who do not have clinical coronary heart disease, diabetes mellitus,
chronic kidney disease, severe inflammatory disease, or contraindications to statins. A C-reactive protein
level may also be reasonable in younger patients with intermediate, but not low, cardiovascular risk.
Measurement of cardiac calcium levels is reasonable in patients whose cardiovascular risk is intermediate
(10-year risk 10%-20%) or low-to-intermediate (10-year risk 6%-10%). An ankle-brachial index is
reasonable for intermediate-risk, but not low-risk, patients. At this point in time, the patient described here
does not meet any recommended criteria for further testing.
A 64-year-old male with a previous history of hypertension and atrial fibrillation presents with
an acute onset of ataxia, headache, mild confusion, and restlessness. His only current
medications are lisinopril (Prinivil, Zestril) and warfarin (Coumadin). On examination his blood
pressure is 160/100 mm Hg, pulse rate 86 beats/min, respirations 12/min, and temperature
36.7°C (98.1°F). A CBC, serum electrolyte levels, and cardiac enzyme levels are normal. His
INR is 1.1. Noncontrast CT shows a cerebellar hemorrhage with a hematoma volume of 50 mL.
Which one of the following should be performed urgently?
A) Neurosurgical consultation for posterior cerebellar hematoma decompression
B) A reduction in blood pressure to 140/90 mm Hg
C) Administration of vitamin K, 10 mg intravenously
D) Administration of mannitol (Osmitrol), 0.5-1.0 mg/kg intravenously
E) Induction of hypothermia to achieve a body temperature of 34.4°C (94.0°F)
Heart murmurs are common in children and adolescents. Often the murmur is innocent, but it may also
be the only finding in an asymptomatic child with structural heart disease. Physical findings that should
lead one to consider evaluation for structural heart disease include increased intensity with standing, a
holosystolic murmur, a grade of 3 or higher, a harsh quality, an abnormal S2, maximal intensity at the
upper left sternal border, a diastolic murmur, or a systolic click. Characteristics that are more likely to be associated with innocent murmurs include a systolic murmur, a
soft sound, a short duration, a musical or low pitch, intensity that varies with phases of respiration,
increased loudness in the supine position, and increased loudness with exercise, anxiety, or fear. If the
diagnosis of an innocent murmur cannot be made from physical findings, an echocardiogram is the most
appropriate study. A chest radiograph and EKG rarely assist in the diagnosis of heart murmurs in children
(SOR B) and should not routinely be ordered.
Drugs such as lithium, thiazide diuretics, sex hormones, and vitamins A and D can increase the serum
ionized calcium level. The gastrointestinal symptoms associated with lithium toxicity are also the most
common presenting symptoms of hypercalcemia. Hypercalcemic patients may also complain of
constipation, fatigue, lethargy, polyuria, and weakness, all the result of an increased serum level of ionized
calcium (roughly calculated to be 40% of the total serum calcium level plus 0.8 g/dL for each 1 g/dL
decrease in serum albumin below 4 g/dL). The most common causes of hypercalcemia are malignancy and
hyperparathyroidism, together accounting for over 80% of all cases. Excessive ingestion of antacids can
result in milk-alkali syndrome, another cause of hypercalcemia. Granulomatous disease and renal diseases
are other possible causes.
Although additional details are required in this case to determine the cause, primary hyperparathyroidism
augmented by medications is highly likely given the patient's age and sex, and measurement of her
parathyroid hormone level must be included in the workup. No matter the cause, the treatment of
symptomatic hypercalcemia should be immediate and directed at lowering the serum calcium level. The
safest and most effective way to accomplish this is with intravenous normal saline volume replacement,
reducing the need for reabsorption of salt, water, and, coincidentally, calcium in the proximal tubules.
Because hypercalcemia often results in volume depletion, aggressive fluid replacement is often ideal,
provided there is no contraindication to doing so. Once the volume depletion is corrected the addition of
loop diuretics such as furosemide can facilitate excretion of calcium. Each of the other options has a place
in the longer term treatment of hypercalcemia in appropriate situations: bisphosphonates for malignancy,
glucocorticoids for granulomatous disease, and cinacalcet for hyperparathyroidism.
While spondylolysis occurs in 6% of the general population, it may be the cause of 50% of back pain in
young adults. This unilateral or bilateral vertebral defect of the pars interarticularis is likely due to
repetitive hyperextension of the posterior spine that results in a fracture or stress injury. This usually
occurs at L4-L5. Sports that put increased demands on the spine include football, gymnastics,
weightlifting, soccer, volleyball, and ballet.
The recommended initial study for athletes with back pain of more than 3 weeks' duration is lumbar spine
radiographs, including anterior/posterior, lateral, and oblique views bilaterally. The "Scotty dog with a
collar" sign can be noted on the oblique view. This may not be present in early spondylolysis, so a SPECT
scan may be appropriate.
Treatment for spondylolysis consists of discontinuing the offending activity, medication for pain, physical
therapy, and possibly bracing. Healing may take 9-12 months.
The diagnosis of occupational asthma can be made when both bronchospasm and its relationship to the
work environment can be demonstrated. A history of cough, wheezing, chest tightness, or episodic
dyspnea in varying combinations or singly should lead one to suspect bronchospasm. Relating
bronchospasm to the work environment can be done in several ways. A history of exposure to a known
sensitizer is helpful, as is a pattern of symptoms occurring after exposure. With many agents the onset of
symptoms may be delayed up to several hours. A 10% decrease in FEV1 measured before and after a work
shift supports the diagnosis. Improvement of bronchospasm with removal from exposure also suggests the
diagnosis. Treatment includes both standard pharmacologic therapy and removal from exposure as soon
Hypersensitivity pneumonitis is an immune-mediated syndrome that is not as common as occupational
asthma. It begins with malaise, fever, and myalgias 4-6 hours after exposure to an antigen to which the
person has become sensitized. Byssinosis is due to exposure to the dust of hemp, flax, or cotton.
Symptoms vary from reversible chest tightness on one or more days early in the work week to chronic
bronchitis and permanent obstructive lung disease. Toxic pneumonitis or pulmonary edema is the result
of very high exposure to irritant gases, metal dust, or metal fumes, usually associated with unusual
circumstances such as a fire, explosion, or spill. Benign pleural effusions are the most common sequela
during the first 20 years after asbestos exposure. The diagnosis is one of exclusion, made by ruling out
other causes of exudative effusions in workers with known asbestos exposure.
Currently, nonalcoholic fatty liver disease is the leading cause of transaminase elevations, and is becoming
increasingly common as obesity becomes more prevalent. It is estimated that some 30% of adults in the
United States have this disease. Patients with metabolic syndrome, diabetes mellitus, or elevated
triglycerides are at the highest risk. If the AST/ALT ratio is >2, especially if -glutamyl transpeptidase
is elevated, alcoholic liver disease should be suspected.
It is well known that severe hepatotoxicity can occur with acetaminophen overdoses, and dosages of even
4 g/day for 5-10 days will cause enzyme elevations in more than half of healthy nondrinkers. Herbal
preparations associated with elevated liver enzymes include kava and germander. Hepatitis C can cause
transient enzyme elevations, typically of ALT.
If liver enzymes remain elevated on a repeat test 2-4 weeks later, the patient should be tested for hepatitis
B and C, and iron, iron binding capacity, and ferritin levels should be ordered to check for
hemochromatosis. A lipid profile and glucose level should be ordered as well, and abdominal
ultrasonography considered to look for evidence of fatty infiltration of the liver.
Cervical spondylotic myelopathy (CSM) is the most common cause of spinal cord dysfunction in the
elderly. Degenerative changes in the cervical spine, such as osteophyte formation, stiffened and
hypertrophied ligamentum flava, and spinal stenosis, can result in spinal cord compression. Symptoms
usually develop insidiously and may include neck stiffness, pain in the arm(s), tingling or numbness in the
hands, and weakness of the hands or legs. Flexion of the neck may produce a shock-like sensation down
the back, known as Lhermitte's sign.
Sensory abnormalities may vary. Hyperreflexia is a characteristic physical finding. The gait may be stiff
or spastic, and atrophy of the intrinsic muscles of the hands is common. CSM can be differentiated from
amyotrophic lateral sclerosis (ALS) by the fasciculations and leg atrophy seen in ALS. Other conditions
that produce similar findings include multiple sclerosis and masses such as a metastatic tumor.
The primary diagnostic test is MRI of the cervical spine. Plain films are of little use as an initial diagnostic
procedure. Electromyography is usually not helpful, although it is occasionally needed to exclude
Nonsurgical treatment such as cervical bracing may be used in mild cases of CSM, but once a frank
myelopathy occurs surgical intervention is the only option. Studies on bracing show variable results,
although it is reported that symptomatic patients may deteriorate neurologically during bracing.
Celiac sprue (gluten-sensitive enteropathy) classically presents as a malabsorption syndrome associated
with dermatitis herpetiformis. This dermatitis usually appears as excoriated papules, as it is extremely
pruritic. The rash may be misdiagnosed as atypical psoriasis or nonspecific dermatitis. With the
development and use of better diagnostic tests, it now appears that this disorder has been underdiagnosed.
Symptoms include fatigue, weight loss, diarrhea, abdominal pain, anemia, bone pain, aphthous ulcers,
stomatitis, infertility, impotence, alopecia areata, dental enamel defects, seizures, ataxia, and dermatitis.
Serologic tests are now available to aid in confirming the diagnosis of celiac sprue, including IgA
antigliadin antibody, IgG antigliadin antibody, IgA antiendomysial antibody, and IgA antitransglutaminase.
Cystic fibrosis, Crohn's disease, and anorexia nervosa can cause weight loss but not dermatitis. Sprue
affects the small intestine; a biopsy of the colon would be inappropriate given this presentation.
All patients who present with palpitations should be evaluated for a cardiac cause, since this is the etiology
in 43% of cases. A standard 12-lead EKG is the initial test of choice and, along with a history and physical
examination, can determine the cause in 40% of cases. A normal resting EKG does not exclude a cardiac
arrhythmia. Therefore, if the EKG is normal, palpitations of suspected arrhythmic etiology may require
further investigation with ambulatory EKG monitoring.
Echocardiography is helpful in evaluating patients for structural heart disease and should be performed
when the initial history, physical examination, and EKG are unrevealing, or in patients with a history of
cardiac disease or more complex signs and symptoms. This patient's family history, along with the fact
that she takes no medications, suggests the possibility of familial long QT syndrome, which often can be
diagnosed from a resting EKG. Diagnosing long QT syndrome is important, since it is associated with an
increased risk of sudden cardiac death. Based on the patient's clinical presentation and evaluation, hospital
admission is not warranted prior to obtaining a standard 12-lead EKG.
Any patient with risk factors for infection who presents with acute joint swelling, pain, erythema, warmth,
and joint immobility should be evaluated for septic arthritis. Risk factors for septic arthritis in this patient
include a cutaneous ulcer and diabetes mellitus. Serum markers such as the WBC count, erythrocyte
sedimentation rate, and C-reactive protein levels are often used to determine the presence of infection or
inflammatory response. However, patients with confirmed septic arthritis may have normal erythrocyte
sedimentation rates and C-reactive protein levels.
Because the clinical presentation of septic arthritis may overlap with that of other causes of acute arthritis,
arthrocentesis is needed to differentiate between the various causes and, in the case of septic arthritis, to
identify the causative agent and determine appropriate therapy. No findings on imaging studies are
pathognomonic for septic arthritis. Antinuclear antibody studies may be indicated later in the course of
management if synovial fluid analysis is not consistent with infection, and if synovial fluid cultures are
A prolonged grief reaction, postpartum depression, and iron deficiency anemia could all cause fatigue,
apathy, and decreased libido, but none of these conditions is characterized by failure to lactate and
amenorrhea. This patient most likely has postpartum pituitary necrosis (Sheehan's syndrome), a
complication of childbirth in which hemorrhagic shock leads to pituitary necrosis. The syndrome is caused
by the lack of hormonal influence from the anterior pituitary gland on other endocrine glands, resulting
in failure to lactate, breast atrophy, mental apathy, low blood pressure, absence or deficiency of sweating,
loss of secondary hair characteristics and libido, and loss of ovarian function, resulting in amenorrhea.
Although the registration of death is a state function and the details may vary based on the laws and
regulations of each state, recorded data is contractually shared with the National Vital Statistics System.
To ensure consistency of reporting, the National Center for Health Certificates coordinates collection of
the data points by providing a standard form which most state certificates are modeled from. The standard
format includes a section titled "Cause of Death," which is subdivided into two parts. In part 1, the
immediate cause of death is to be recorded on the top line (labeled "a"). This is defined as the final
disease, injury, or complication directly causing the death, and the directions clearly state that terminal
events such as cardiac arrest, respiratory arrest, or ventricular fibrillation are not to be entered without
showing the etiology.
Additional lines are provided to list conditions leading to the cause of death, including a final line for
entering the disease or injury that initiated the process leading to death. In this case, the proximate cause
of death was the upper gastrointestinal hemorrhage. The source of the bleeding was most likely from
esophageal varices resulting from hepatic cirrhosis, so those conditions should be entered respectively in
the next two lines. The appropriate entry for the final line in part 1 would be chronic alcoholism.
Space is provided in part 2 to include significant conditions contributing to death, such as other chronic
illness and tobacco use.
Erythema, redness, and pain in the first metatarsal-phalangeal joint are typical symptoms of gout. The uric
acid level can be normal at various times in gout. Acute synovitis is occasionally caused by apatite
deposition disease, but it is usually associated with long-standing osteoarthritis, and the joints involved are
most commonly the shoulder, hip, and knee. Morton's neuroma is an entrapment neuropathy of the
interdigital nerve, usually occurring between the third and fourth toes, not associated with erythema and
redness. Acute arthritis in systemic lupus erythematosus typically involves the wrists, the small joints of
the hands, and the knees.
This patient most likely has a psychogenic tremor, given its abrupt onset, spontaneous remission, changing
tremor characteristics, and extinction with distraction (SOR C). Other characteristics of this case that
suggest psychogenic tremor are the associated stressful life event, the patient's employment in a health care
setting, and no evidence of disease by laboratory or radiologic investigations. In addition, the tremor
increases with attention and has been unresponsive to anti-tremor medications (SOR C).
Dystonic tremor is a rare tremor found in less than 1% of the population, and other signs of dystonia, such
as abnormal flexion of the wrists, are usually present. Essential tremor is an action tremor and is usually
postural; however, persons with essential tremor typically have no other neurologic findings. Essential
tremor typically improves with alcohol consumption (2 drinks/day). A cerebellar tremor is usually
associated with other neurologic signs, such as dysmetria (overshoot on finger-to-nose testing), dyssynergia
(abnormal heel-to-shin testing and/or ataxia), and hypotonia. A parkinsonian tremor is most often a resting
tremor, and although it may become less prominent with voluntary movement, it usually does not
Testosterone replacement therapy can improve many of the effects of hypogonadism. Beneficial effects
include improvements in mood, energy level, sexual functioning, sense of well-being, lean body mass and
muscle strength, erythropoiesis, bone mineral density, and cognition. However, there are also some risks
associated with testosterone use, including an increased risk for prostate cancer, worsening of symptoms
of benign prostatic hyperplasia, liver toxicity and tumor, worsening of sleep apnea and heart failure,
gynecomastia, infertility, and skin diseases. Testosterone replacement therapy is not appropriate in men
who are interested in maintaining fertility, as exogenous testosterone will suppress the
In addition to their lipid-lowering effects, statins have been shown to have plaque-stabilizing and vascular
anti-inflammatory effects. There is strong clinical evidence that perioperative statin therapy, even when
initiated within days of the procedure and without regard to lipid levels, significantly reduces
cardiovascular risk for patients undergoing vascular surgery (SOR A).
There is strong clinical evidence of benefit in perioperative cardiovascular risk reduction for continuation
of -blockers before, during, and after vascular surgery in patients who have been on them for at least 4
weeks preoperatively (SOR A). However, in patients who have not been on a beta-blocker for at least 1-4
weeks preoperatively, initiation prior to surgery may be harmful (SOR B).
Traditionally, aspirin has been discontinued prior to surgery for fear of increased surgical bleeding
complications. However, studies have shown that in most cases it is safe to continue low-dose aspirin in
the perioperative period, and doing so reduces cardiovascular complications. This is especially true for
patients with a past history of myocardial infarction or with coronary stents (SOR B).
Preoperative cardiac stress testing is of little value in patients with low or medium cardiovascular risk
status, such as the patient described here. Enoxaparin would not be indicated preoperatively in this patient.
The range of normal hemoglobin values for healthy individuals varies with age, sex, pregnancy, smoking,
altitude, and ethnicity to an extent that an adjustment derived from population-based studies is appropriate
in each of these situations. A healthy individual should have their lifetime highest hemoglobin
concentrations at full-term birth, exclusive of any later changes from altitude or smoking. Hemoglobin
levels fall during the first 2 months of life and thereafter gradually increase until stabilizing at
approximately 6 months of age.
Studies of ethnic groups in the U.S. demonstrate no significant differences in normal hemoglobin values
among East Asians, Hispanics, Japanese, Native Americans, and non-Hispanic whites; hemoglobin values
of African-Americans tend to be 1 g/dL lower compared to the other U.S. ethnic groups studied. Living
at higher altitudes has a direct effect on hemoglobin levels, and a hemoglobin reference range adjustment
of +1 g/dL at 1000 meters up to +5.5 g/dL at 5000 meters is appropriate. Similarly, smoking increases
hemoglobin levels by 3 g/dL for a 1 pack/day smoker to as high as +7 g/dL for individuals smoking more
than 2 packs/day. The plasma volume expansion that occurs during pregnancy results in a 1.0-1.5 g/dL
reduction in normal hemoglobin levels.
It is estimated that about one-third of patients with bipolar disorder seek medical care within a year of the
onset of symptoms, but that nearly 70% do not receive an accurate diagnosis. The symptoms can often be
subtle and may be attributed to other causes by patients or their loved ones.
A diagnosis of attention-deficit disorder requires that a patient's symptoms be present since early
childhood, although they are sometimes not recognized at the time. This patient and his girlfriend have
both acknowledged that he is not his usual self. He presents with increased self-esteem, a decreased need
for sleep, pressured/tangential speech, and irritability, which point to the possibility of a manic or
hypomanic episode. Together these symptoms suggest bipolar disease (SOR C). Patients with full-blown
mania are often out of touch with reality and easy to identify. However, patients with hypomania consider
themselves to have increased well-being and productivity, and will not always seek attention or consider
themselves to have a problem.
Other symptoms that should alert the physician to this diagnosis include substance abuse (present in over
70% of cases) and involvement in other pleasurable but destructive activities such as overspending or
hypersexuality. If substance abuse is present, however, it must be addressed before making a diagnosis
of bipolar disorder. Bipolar disorder is highly genetic, and asking about affected first degree family
members can often assist in making the diagnosis.
Allergic reactions to medications have four primary mechanisms, referred to as Gell and Coombs
classifications. The most frequent forms are type I reactions, which are immediate and mediated through
IgE, and type IV reactions, which are delayed and mediated through T-cell hypersensitization. Severe type
I reactions are often referred to as anaphylaxis and are the most likely to be life threatening with very little
warning. Recognition of the early signs of anaphylaxis is the first step in preventing such catastrophes.
Anaphylactic reactions result from a massive release of histamine and start with pruritus around the mouth,
on the scalp, and on the palms and soles; flushing of the face and neck, with rhinitis and conjunctivitis;
angioedema of the oral mucosa, especially of the pharynx and larynx; severe urticaria; dyspnea and
bronchospasm (especially in known asthmatics); and hypotension. A delay in lifesaving therapy during this
phase will result in full shock, hypotension, and death. Type IV reactions usually result in benign, diffuse
erythematous macules on the trunk and proximal extremities, often referred to as a drug rash. These
reactions infrequently become more severe and rarely are life threatening. In severe cases the lesions
become painful and palpable, and may involve blistering, mucositis, and ecchymosis.
A 68-year-old female with a previous history of multiple medical problems presents to your
office with dizziness. She describes this dizziness as an "off-balance" or "wobbly" feeling. She
has not had a sensation of spinning or motion, or loss of consciousness. She is not anxious or
depressed. She takes the following medications:
Lovastatin (Mevacor), 20 mg daily for hypercholesterolemia
Metoprolol succinate (Toprol-XL), 25 mg daily
Chlorthalidone, 12.5 mg daily
Lisinopril (Prinivil, Zestril), 20 mg daily for hypertension
Sertraline (Zoloft), 25 mg daily for menopausal symptoms
Alendronate (Fosamax), 70 mg weekly
Calcium, 600 mg 2 times daily
Vitamin D, 1000 units daily for osteoporosis
Oxybutynin (Ditropan XL), 10 mg daily for overactive bladder
Acetaminophen, 1000 mg 2 times daily for osteoarthritis
Meclizine (Antivert, Bonine), 25 mg 3 times daily as needed for dizziness
Cyclobenzaprine (Flexeril), 5 mg 3 times daily as needed for muscle spasm
Zolpidem (Ambien), 5 mg at bedtime as needed
A physical examination is normal, including a neurologic examination, and the patient has a
normal gait. There is no evidence of peripheral neuropathy, and Romberg testing is normal.
There is no orthostatic decrease in blood pressure. The Dix-Hallpike maneuver is negative. A
CBC, chemistry profile (CMP), TSH level, and vitamin B12 level are normal.
Which one of the following would be most appropriate at this point?
A) A 24-hour heart monitor
B) A tilt table test
C) Carotid ultrasonography
D) Medication reduction
E) Increasing the dosage of sertraline to 50 mg daily
A 49-year-old female with type 1 diabetes mellitus presents to your office with a 1-week history
of a red, hot, swollen foot. She recalls twisting her ankle when stepping off a curb the day
before the swelling began. She denies fever or significant pain. She has difficulty walking due
to stiffness in the foot.
On examination you find the patient is in no distress. Her temperature is 36.7°C (98.1°F), blood
pressure 144/82 mm Hg, and heart rate 80 beats/min. Her right foot is edematous,
erythematous, and excessively warm. Monofilament testing reveals significant impairment of
sensation of both feet. She has restricted range of motion of the right ankle and foot compared
to the left. No skin lesions are present. Dorsalis pedis pulses are brisk and symmetric. A
radiograph of the right foot is normal.
Capillary blood glucose...213 mg/dL
Hematocrit... 37.2% (N 36.0-46.0)
WBCs... 11,000/mm3 (N 4300-10,800)
Platelets...350,000/mm3 (N 150,000-350,000)
Erythrocyte sedimentation rate... 30 mm/hr (N 1-25)
Which one of the following is the most likely diagnosis?
C) Acute gout
D) Charcot foot
This patient most likely has Charcot foot (neuropathic arthropathy). This is an uncommon condition, most
often found in patients with at least a 10-year history of type 1 or 2 diabetes. Patients have peripheral
neuropathy and typically present with painless swelling of a foot. About 50% of patients can recall minor
trauma preceding the onset of symptoms. Early radiologic findings may be normal, but as the condition
progresses plain films may reveal bony fractures, fragmentation, and bone destruction. On examination
the foot is either stiff or hypermobile, warm, erythematous, and edematous. Crepitus can be felt in later
stages of the disease. Laboratory results can be normal or show increases in the WBC count. Any patient
with long-standing diabetes mellitus and a warm, red, swollen foot should be presumed to have Charcot
foot and have the foot immobilized immediately to protect it from stress and to prevent further destruction
and disability (SOR C).
The differential diagnosis of Charcot foot includes osteomyelitis, which can be difficult to distinguish.
Patients with osteomyelitis can have skin ulcers that may be probed to the bone. They will often be febrile,
with higher erythrocyte sedimentation rates and WBC counts than patients with Charcot foot. Aspiration
of the joint fluid is helpful in distinguishing between the two conditions.
Aspiration can also help distinguish between acute gout and Charcot foot. Patients may have pain and
stiffness in their foot with either condition. Patients with gout may have an elevated uric acid level, and
plain films may reveal tophi.
Patients with osteoarthritis are unlikely to have warm, erythematous skin overlying the involved joint.
Symptoms often have an insidious onset rather than the more acute onset of Charcot foot.
General recommendations regarding prevention of recurrent nephrolithiasis include increasing fluid intake
up to 2 L of water daily (SOR B); greater volumes may lead to electrolyte disturbances and are not
recommended. More specific dietary recommendations depend on the stone type. If the stone is not
recovered, the type may be inferred from a 24-hour urine collection for calcium, phosphorus, magnesium,
uric acid, and oxalate.
Approximately 60% of all stones in adults are calcium oxalate. Uric acid stones account for up to 17% of
stones and, like cystine stones, form in acidic urine. Alkalinization of the urine to a pH of 6.5-7.0 may
reduce stone formation in patients with these types of stones. This includes a diet with plenty of fruits and
vegetables, and limiting acid-producing foods such as meat, grains, dairy products, and legumes. Drinking
mineral water, which is relatively alkaline with a pH of 7.0-7.5, is also recommended. Restriction of
dietary oxalates has not been shown to be effective in reducing stone formation in most patients.
Acidification of the urine to a pH 7.0 is recommended for patients with the less common calcium
phosphate and struvite stones. This can be accomplished by consumption of at least 16 oz of cranberry
juice per day, or by taking betaine, 650 mg three times daily.
Somatization disorder usually begins in the teens or twenties and is characterized by multiple unexplained
physical symptoms, insistence on surgical procedures, and an imprecise or inaccurate medical history.
Abuse of alcohol, narcotics, or other drugs is also common in these patients.
Hypochondriacs are overly concerned with bodily functions, and can often provide accurate, extensive,
and detailed medical histories. Malingering is an intentional pretense of illness to obtain personal gain.
Patients with panic disorder have episodes of intense, short-lived attacks of cardiovascular, neurologic,
or gastrointestinal symptoms. Generalized anxiety disorder is characterized by unrealistic worry about life
circumstances accompanied by symptoms of motor tension, autonomic hyperactivity, or vigilance and
This patient almost certainly has sarcoidosis. The diagnosis is supported by a compatible clinical and
radiographic presentation, and histologic evidence of noncaseating granulomas on a biopsy (without
organisms or particles). In patients who present with Löfgren syndrome (erythema nodosum, hilar
adenopathy, and polyarthralgias), a probable diagnosis of sarcoidosis can be made without a biopsy. In
all other cases a biopsy should be performed on the most accessible organ, such as the skin or peripheral
While the thorax is the most common site of disease, skin involvement occurs in at least 30% of patients
and is often missed. This patient was diagnosed with psoriasis, which may have been another manifestation
of sarcoidosis. Cutaneous sarcoidosis presents as single foci or crops, and is often attributed to other
causes, perhaps because of its highly variable manifestations such as macular-papular, nodular,
psoriatic-like, and hypomelanotic lesions. Careful skin examination is warranted because biopsy of a
sarcoidal lesion has a high diagnostic yield.
Problems with gait and balance increase in frequency with advancing age and are the result of a variety
of individual or combined disease processes. Findings may be subtle initially, making it difficult to make
an accurate diagnosis, and knowing the relative frequencies of primary causes may be useful for
management. A cautious gait (broadened base, slight forward leaning of the trunk, and reduced arm swing)
may be the first manifestation of many diseases, or it may just be somewhat physiologic if not excessive.
In the past, a problematic gait abnormality in an elderly person was generally termed a senile gait if there
was no clear diagnosis; it is more accurate, however, to describe this as an undifferentiated gait problem
secondary to subclinical disease. From the long list of potential causes, arthritic joint disease is by far the
most likely to be seen in the family physician's office, accounting for more than 40% of total cases. It most
frequently causes an antalgic gait characterized by a reduced range of motion. The patient favors affected
joints by limping or taking short, slow steps.
Although Medicare does not pay for an "annual physical," it does provide for annual preventive screening
services, including a complete health history and an array of screening measures for depression, fall risk,
cognitive problems, and other challenges. The physical examination conducted as part of the annual
wellness visit includes measurement of blood pressure and weight, a vision check, and hearing evaluation,
as well as additional elements depending on the individual's health risks.
While questioning the patient or caregiver regarding perceived hearing difficulties may suffice when
screening for hearing loss, screening for vision loss requires use of a standard screening tool.
Documentation of visual acuity by use of the Snellen chart is an accepted means of screening for visual
acuity in the primary care setting (SOR A). Vision screening will not pick up age-related macular
degeneration or cataracts, however.
To address and minimize perioperative neurologic morbidity in patients undergoing coronary artery bypass
grafting (CABG), individualized surgical management strategies are now recommended. These address
patient risk factors for postoperative stroke, such as carotid stenosis, hypertension, older age, a past history
of stroke, small-vessel disease in the brain, and diabetes mellitus. Because concomitant carotid disease is
often associated with CAD, pre-CABG carotid Doppler ultrasonography is routinely recommended.
Several approaches have been evaluated for decreasing the risk associated with carotid stenosis.
Performing both carotid and CABG surgery at the same time increases stroke risk, and no studies have
compared doing one before the other. While the use of statins has increased in patients with systemic
atherosclerosis, the roles of both postoperative statins and beta-blockers are still controversial. The only
treatment that has been shown to reduce postoperative cerebrovascular events is the use of aspirin in the
first 48 hours after surgery.
While vacationing, a 27-year-old white male was exposed to poison ivy. Between 48 and 72
hours after exposure he developed a pruritic, erythematous, papulovesicular eruption on his arms
and neck. He began treating himself with an over-the-counter topical hydrocortisone cream, and
when the eruption did not improve after 24 hours of treatment he sought help from the local
emergency department. He was given oral methylprednisolone (Medrol Dosepak), starting with
24 mg/day and tapered by 4 mg/day over 6 days. His condition began to improve, but on day
6 he noted a dramatic exacerbation of the eruption with intense pruritus, erythema, and
vesiculation, involving extensive areas of his arms, neck, and face.
The most appropriate management at this time would be to
A) prescribe a superpotent topical corticosteroid
B) repeat the oral methylprednisolone treatment
C) begin diphenhydramine (Benadryl), 4 times a day
D) begin high-dose oral prednisone and taper over 2 weeks
E) discontinue all medications and recommend cool compresses
The first step in diagnosing deep-vein thrombosis (DVT) is to complete a validated clinical prediction
inquiry such as the Wells Clinical Prediction Rule in order to estimate the pretest probability of DVT. The
Wells criteria include such factors as active cancer, calf swelling, pitting edema, prolonged inactivity, or
major surgery within the previous 12 weeks.
The next step for patients with a low pretest probability of DVT is a high-sensitivity D-dimer assay, with
a negative result indicating a low likelihood of DVT (SOR A). D-dimer is a degradation product of
cross-linked fibrin blood clots and is usually elevated in patients with DVT, although it can also be elevated
with other conditions such as recent surgery, hemorrhage, trauma, pregnancy, or cancer. If the assay is
negative, the likelihood of DVT is very small.
In this case, the patient has several factors listed in the Wells criteria, indicating a high pretest probability
of DVT. D-dimer testing would not be useful, as the next step in this patient's evaluation should be
imaging. Ultrasonography is the best test for symptomatic proximal-vein thrombosis, with a sensitivity
ranging between 89% and 96% (SOR A). Although ultrasonography is the most appropriate first imaging
test, contrast venography is considered the definitive test to rule out the diagnosis of DVT if there is still
a high degree of suspicion after negative ultrasonography.
Helical CT is commonly used to detect pulmonary embolism but is not routinely recommended to diagnose
DVT. Similarly, MRI is not routinely recommended for detecting DVT.
The extended flat pharmacokinetic curve of long-acting insulin analogues makes once-daily administration
of larger doses of insulin possible. Such treatment should, in theory, provide increased flexibility with
regard to the timing of injections and improve compliance. This should improve control of the patient's
diabetes, reduce the risk of hypoglycemia, and improve overall patient satisfaction. To date, however, the
only proven benefit of treatment with insulin analogues is a reduction in the low rate of symptomatic,
nocturnal, and overt hypoglycemia experienced by patients treated with isophane insulin. Although the total
cost of treatment with insulin analogues is higher, a Cochrane review of the limited number of studies
comparing insulin treatments showed no statistically significant differences in the hemoglobin A1c levels
measured at the end of the studies in any treatment group (SOR C). Significant changes in morbidity,
mortality, or quality of life have not been demonstrated (SOR C).
Thrombotic thrombocytopenic purpura (TTP) is an emergent condition that can result in up to 30%
mortality. Prompt hospitalization with plasma exchange is the preferred treatment. Patients with TTP
present with nonspecific symptoms such as fever, abdominal pain, nausea, and weakness. Patients may
also exhibit neurologic deficits. Microangiopathic anemia is also likely to be present, as evidenced by
schistocytes on a peripheral smear and elevated levels of LDH and nucleated RBCs.
Congenital thrombocytopenia is a benign condition in which patients have long-standing low platelet counts
and/or a family history of thrombocytopenia. It is usually asymptomatic but a concomitant bleeding
diathesis may occur.
Gestational thrombocytopenia is also benign and asymptomatic. It is often confused with mild immune
thrombocytopenic purpura. Platelet counts rarely drop below 70,000/mm3. There is no associated fetal
thrombocytopenia. Preeclampsia and HELLP syndrome should also be ruled out. Platelet counts return
to normal after delivery (SOR C).
Drug-induced thrombocytopenia can be severe, but platelet counts do not usually drop below 20,000/mm3.
It is characterized by an abrupt drop in the platelet count within a week of starting the offending medication
and resolves within 2 weeks after the medication is stopped.
Lyme disease can be associated with a transient thrombocytopenia. Patients present with common
symptoms of Lyme disease, such as fever, myalgias, and rash. The thrombocytopenia resolves with
treatment of the underlying infection.
Joint pain in the presence of fever with no apparent source indicates a possible infection, malignancy, or
rheumatologic condition and requires further workup. Laboratory evaluation, including a CBC, a
C-reactive protein level, and an erythrocyte sedimentation rate can help assess for these conditions, even
though none of the tests is sufficiently sensitive to rule out these diseases, and they are not specific to a
single disease entity. Knee joint aspiration would be indicated to rule out septic arthritis in the presence
of a joint effusion. If the hip were painful or had decreased range of motion, then ultrasonography could
help identify a hip joint effusion, which would need to be aspirated. MRI may be needed in this patient,
but it would likely require sedation and thus is more invasive. Starting with laboratory work is a good first
step toward identifying the source of his pain and fever.
Recommendations for reducing ventilator-associated pneumonia (VAP) include elevation of the head to
an angle of at least 30°, noninvasive mechanical ventilation rather than intubation when appropriate, oral
intubation when an endotracheal tube is necessary, orogastric rather than nasogastric tubes, minimization
of sedation, administration of a proton pump inhibitor when prophylaxis is indicated, changing ventilator
tubing every 7 days or when it becomes soiled, avoidance or elimination of endotracheal tube leaks, good
technique in removal of condensate, and excellent hand hygiene. One study favored waiting more than 5
days before initiating tube feedings, as this reduced the incidence of VAP, although further data is needed
to confirm this.