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Terms in this set (241)

ANSWER: E
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
population groups.
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.
ANSWER: D
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.
ANSWER: E
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
as possible.
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.
ANSWER: C
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.
ANSWER: E
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.
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
ANSWER: D
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).
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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.
ANSWER: E
Research has consistently confirmed that stimulant medications are the most efficacious first-line treatment
for children with attention-deficit/hyperactivity disorder (ADHD) (SOR A). No research supports the
notion that the use of a stimulant in ADHD patients will promote addiction. To the contrary, some evidence
suggests that ADHD patients who take stimulant medication have lower rates of drug abuse than those who
do not. Diversion and misuse of prescription stimulants is a growing concern, however, and the use of a
long-acting stimulant can decrease the chances for diversion.
There are a number of well-supported behavioral interventions for ADHD. Most behavioral approaches
focus on rewarding desired behavior and applying consequences for unwanted behavior to gradually
reshape the child's thinking and actions. Interventions that help reinforce parental involvement include
support groups, which connect parents who have children with similar problems, and parenting skills
training, which gives parents techniques and tools for managing their child's behavior. Psychotherapy and
cognitive-behavioral therapy have little or no documented effectiveness for the treatment of ADHD.
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A multicenter, randomized study comparing the effectiveness of multimodal treatment (combined
behavioral interventions and pharmacotherapy) with either treatment alone showed that combination
treatment and pharmacotherapy alone yielded similar results and each was more effective than behavioral
treatment alone or standard care in reducing core ADHD symptoms. A tool kit has been developed by the
American Academy of Pediatrics and the National Initiative for Children's Healthcare Quality to help
physicians improve the management of ADHD. While the second edition is only available in print form,
the first edition can be downloaded free at http://www.nichq.org/adhd_tools.html.
ANSWER: C
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.
ANSWER: D
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.