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Terms in this set (149)

Correct Answer ( A )

Giant cell arteritis (GCA), as known as temporal arteritis, is the most common primary vasculitis of the elderly, and predominately affects those aged over 50 years. It is a syndrome of systemic inflammation which mainly affects the branches of the internal and external carotid arteries, but it can affect any vessel in the body. The most common symptoms are a temporal or occipital headache, jaw claudication (mandibular, tooth and tongue pain with chewing tough foods), visual changes (partial or complete blindness, diplopia, visual field cuts or amaourosis fugax) and arthralgias. It is associated with constitutional symptoms, anemia, an enlarged tender nodular erythematous temporal artery, ESR > 50 mm/hour and polymyalgia rheumatica. Temporal artery biopsy confirms the diagnosis. Since unilateral partial or complete blindness occurs in up to 20% of patients with GCA, immediate treatment is necessary when this condition is suspected. High-dose corticosteroids are the standard treatment, and typical options include 40-60 mg per day of oral prednisone, or intravenous methylprednisolone. High-dose therapy is usually continued for 2-4 weeks, and titrated against visual and headache improvement, not serial ESR monitoring. After symptoms lessen, steroids are slowly tapered over 6 months, with complete tapering off in 2 to 3 years. As such, the clinician must monitor for complications of long-term corticosteroid therapy. These include hypertension, diabetes, osteoporosis, steroid myopathy (proximal weakness), fluid retention, bruising, insomnia, restlessness, hypomania and hypercholesterolemia.

Adjuvant methotrexate (B) is not routinely recommended for treating GCA as studies of its efficacy are inconclusive. If GCA is suspected, intravenous methylprednisolone should be started even before a temporal biopsy (C). Steroids will not affect the validity of a biopsy result until about 3-4 weeks of treatment, however, a delay in steroids may lead to blindness. There is some evidence of the usefulness of temporal artery ultrasonography (D) for detecting the best area of the artery to biopsy. However, a negative ultrasound does not rule out GCA, and furthermore, some studies have shown that temporal artery ultrasound sometimes cannot differentiate degenerative changes from inflammatory changes.
Correct Answer ( C )
Explanation:

Myocarditis is typically caused by a viral infection, most commonly coxsackie B virus, adenovirus, parvovirus B19 and Echovirus. Trypanasoma cruzi (Chagas disease) is the most common etiology worldwide. Myocardial necrosis occurs likely as a result of direct invasion of the offending organism as well cytotoxic effects of the host's immune system. Individuals develop flulike symptoms and in adults chest pain and shortness of breath. One of the hallmark signs of myocarditis is tachycardia out of proportion to fever. Depending on the time of presentation, patients may have symptoms of heart failure as the left ventricular ejection fraction is impaired as a result of the myocarditis. Troponin is often elevated as the disease progresses. The gold standard for diagnosis is endocardial biopsy. Management is supportive. ACE inhibitors help reduce myocardial inflammation.



Acute coronary syndrome (A) is a possibility in this patient but is less likely given her age and absence of medical history. It is also atypical for a person with acute coronary syndrome to have a fever and viral symptoms. Mediastinitis (B) may present with fever, chest pain and shortness of breath. However, there is often a history of either severe retching or a procedure that caused esophageal perforation. Patients with air in the mediastinum from a perforation may have Hamman's sign, a crunching sound on auscultation. Pulmonary embolism (D) does cause chest pain and shortness of breath. Classically the chest pain is pleuritic and flulike symptoms are not associated with the diagnosis. Patients with a pulmonary embolism may have a low-grade fever.
Correct Answer ( D )
Explanation:

Spironolactone is well-established as a contributor to the development of gynecomastia due to its effect on androgen expression. Many medications are implemented in causing gynecomastia, which common offenders being antipsychotics, antifungal medications, high active antiretroviral therapy, and some atypical antidepressants. Fortunately gynecomastia caused by medication use usually resolves with discontinuation of the causative medication. If a medication is not found to be responsible for gynecomastia, other causes should be pursued. Serum beta-hCG levels should be drawn to look for a testicular tumor or other malignancy that may be producing exogenous hormones. Similarly, a prolactin level should be checked to rule out a prolactinoma. Additionally, any male athlete should be asked about taking anabolic steroids as using these will lead to gynecomastia in 50% of users. Other causes to explore based on individual patient profiles may include liver disease, obesity, and primary or secondary hypogonadism. Of note, in teenagers a mild degree of pubertal gynecomastia can be normal and will usually resolve without treatment in 1-2 years. However, any male breast tissue that is asymmetric, unusually firm, forming in a location other than below the areola, or accompanied by nipple bleeding, discharge, or retraction should raise concern for a malignancy. In these patients, a needle biopsy with cytologic examination will help differentiate benign gynecomastia from a tumor or other inflammatory process. When necessary, true glandular gynecomastia usually responds to selective estrogen receptor modulators, such as raloxifene or tamoxifen. Surgical correction may be needed in patients for whom medication therapies are ineffective.

Clonidine (A), hydrochlorothiazide (B), and lisinopril (C) are incorrect choices as these are not particularly well-known for causing gynecomastia in patients.
Correct Answer ( C )
Explanation:

"Strep throat" caused by Group A Beta-hemolytic streptococcus (Streptococcus pyogenes or GAS) is a common etiology of acute pharyngitis especially in children ages 5 to 15. It is characterized by inflammation of the pharynx or tonsils (tonsillar exudates) associated with symptoms of fever, malaise and sore throat, as well as the absence of other URI symptoms such as nasal congestion and cough. Cervical lymphadenopathy is often found on exam, as is a whitish exudate over the pharynx and tonsils. A rapid streptococcal antigen test is recommended in order to determine if treatment with antibiotics is warranted, as other conditions which do not require antibiotic treatment may mimic streptococcal pharyngitis. A throat culture to rule-out GAS infection is recommended in children if rapid antigen testing is negative (90% sensitivity), in order to limit transmission and prevent complications such as rheumatic fever. Other complications of strep throat may include acute glomerulonephritis, peritonsillar abscess, bacteremia, sinusitis and pneumonia. Penicillin-based antibiotics (benzathine penicillin IM or oral penicillin VK) are the treatment of choices. For penicillin allergic patients, azithromycin is an alternative.

Mononucleosis (A) is an infection caused by Epstein-Barr virus and is most common in 15 to 24 year-olds. Patients usually experience a several day prodrome of fever, chills, malaise and anorexia followed by the onset of throat pain, fever and lymphadenopathy. The diagnosis is supported by heterophile (Monospot) antibody testing. Treatment is supportive and the illness is generally self-limited, though some patients may experience residual symptoms of malaise and fatigue for months following initial diagnosis. Sinusitis (B) refers to inflammation of the mucous membranes lining the paranasal sinuses. Patients present complaining of cough, facial tightness, headache, reduced ability to smell and nasal congestion with purulent nasal and postnasal discharge lasting 7-10 days. Sinusitis is usually caused by a virus, leading to decreased clearance of secretions within the mucosa and entrapment of bacteria which may lead to secondary bacterial infection. The three most common bacterial agents involved in sinusitis are Haemophilus influenzae, Streptococcus pneumoniae and Moraxella catarrhalis. Treatment of viral sinusitis is supportive; antibiotics are indicated only if the clinical course strongly suggests bacterial secondary infection. Tonsillolithiasis (D) is a condition caused by chronic inflammation of the tonsils in which small concretions develop within one or both of the tonsils. Symptoms of this condition may include halitosis, foreign body sensation, dysphagia and odynophagia, otalgia, and neck pain, though many patients are asymptomatic. Definitive treatment is surgical removal, though not required if symptoms are not bothersome
Correct Answer ( A )
Explanation:

Congenital cholesteatoma usually appears as a white, round, cystlike structure medial to an intact TM. Cysts are seen most commonly in the anterior-superior portion of the middle ear, although they can present in other locations and within the TM or in the skin of the ear canal. Affected children often have no prior history of otitis media (OM). Congenital or acquired cholesteatoma should be suspected when deep retraction pockets, keratin debris, chronic drainage, aural granulation tissue, or a mass behind or involving the TM is present. Besides acting as a benign tumor causing local bone destruction, the keratinaceous debris of a cholesteatoma is a good culture medium and may become a focus of infection for chronic OM. Complications include ossicular erosion with hearing loss, bone erosion into the inner ear with dizziness, or exposure of the dura, with consequent meningitis or a brain abscess. Cholesteatoma should be removed surgically after CT scan and hearing evaluation, and appropriate antibiotic therapy. A second-look procedure 6-9 months after primary surgery is often recommended to prevent further recurrence. Congenital cholesteatoma is an aggressive disease and needs to be taken care of to prevent permanent damage to the middle and inner ear.

None of the following describe a cholestetoma and all refer to other conditions commonly associated with hyperlipidemia. Corneal arcus (B) is a greyish-white ring (or part of a ring) opacity occurring in the periphery of the cornea, in middle and old age. It is due to a lipid infiltration of the corneal stroma, with age the condition progresses to form a complete ring. That ring is separated from the limbus by a zone of clear cornea. Xanthelasma are localized deposits of fats that collect in the skin of the upper and lower eyelids (C). They can be skin-colored to yellowish and are associated about half the time with elevated blood lipids (fats), including cholesterol and triglycerides, which may be a sign of diabetes. Removal usually requires electric cautery or surgery. Cholesterol plaques are the culprits of heart disease. Plaques begin in artery walls (D) and grow over years. The growth of cholesterol plaques slowly blocks blood flow in the arteries. Worse, a cholesterol plaque can suddenly rupture. The sudden blood clot that forms over the rupture then causes a heart attack or stroke.
Correct Answer ( C )
Explanation:

Midgut volvulus may present in one of three ways: as a sudden onset of bilious vomiting and abdominal pain in a neonate; as a history of "feeding problems" with bilious vomiting that appears to be a bowel obstruction; or less commonly, as failure to thrive with severe feeding intolerance. The classic finding on abdominal plain films is the "double bubble" sign, which shows a paucity of gas (airless abdomen) with two air bubbles, one in the stomach and one in the duodenum. However, the plain film can be entirely normal. The upper gastrointestinal contrast study is considered the gold standard for diagnosing volvulus.

Infantile colic (A) usually begins during the second week of life and typically occurs in the evening. It is characterized by screaming episodes and a distended or tight abdomen. Its etiology has yet to be determined. There are no abnormalities on physical examination and ancillary studies, and symptoms usually resolve spontaneously around 12 weeks of age. Necrotizing enterocolitis (D) is typically seen in the distressed neonate in the intensive-care nursery, but it may occasionally be seen in the healthy neonate within the first 2 weeks of life. The child will appear ill, with symptoms including irritability, poor feeding, a distended abdomen, and bloody stools. Abdominal plain films will show pneumatosis intestinalis, caused by gas in the intestinal wall, which is diagnostic of the condition. Intussusception (B) is seen most frequently between the ages of 3 months and 5 years, with 60% of cases occurring in the first year and a peak incidence at 6-11 months of age. The disorder occurs predominantly in males. The classic triad of intermittent colicky abdominal pain, vomiting, and bloody, mucous stools is encountered in only 20%-40% of cases. At least two of these findings will be present in approximately 60% of patients. The abdomen may be distended and tender, and there may be an elongated mass in the right upper or lower quadrants. Rectal examination may reveal either occult blood or frankly bloody, foul-smelling stool, classically described as "currant jelly." An air enema using fluoroscopic guidance is useful for both diagnosis and treatment.
Correct Answer ( D )

Prevention traditionally has been divided into three categories: primary, secondary, and tertiary. Primary prevention targets individuals who may be at risk to develop a medical condition and intervenes to prevent the onset of that condition. Examples include childhood vaccinations, water fluoridation, smoking cessation, and education about safe sex. The varicella vaccine is an example of primary prevention.

Secondary prevention includes procedures that detect and treat pre-clinical pathological changes and thereby control disease progression. Screening procedures, such as mammography to detect early stage breast cancer, are often the first step, leading to early interventions that are more cost effective than intervening once symptoms appear. Screening is usually undertaken by health professionals, such as routine blood pressure checks or via public health screening programs such as osteoporosis screening. Colonoscopy and Papanicolau test (C) are other common examples of secondary prevention. Tertiary prevention targets individuals with a known disease, with the goal of limiting or preventing future complications. It aids in softening the impact caused by the disease on the patient's function, longevity, and quality of life. Examples include screening diabetics for microalbuminuria, rigorous treatment of diabetes mellitus, and post-myocardial infarction prophylaxis with beta-blockers and aspirin. An annual ophthalmoscope examine in diabetic patients (B) to screen for retinopathy is an example of tertiary prevention. Tertiary prevention can include modifying risk factors, such as assisting a cardiac patient to lose weight, or making environmental modifications to reduce an asthmatic patient's exposure to allergens (A).
Correct Answer ( B )
Explanation:

This patient has subacute thyroiditis which is treated with oral propranolol to manage her symptoms of hyperthyroidism and aspirin to manage pain. Subacute thyroiditis, or deQuervain thyroiditis, is a common, transient condition that usually presents after a recent viral illness, such as an upper respiratory infection. Young and middle-aged women are the typical population. Symptoms include an acute, painful enlargement of the thyroid gland with dysphagia, fever, and fatigue. Pain often radiates to the jaw or ears. Approximately 50% of patients will develop symptoms of thyrotoxicosis, including palpitations, diaphoresis, vomiting or diarrhea, and a high fever. Laboratory findings will include a suppressed TSH, elevated free T4 levels, and markedly elevated erythrocyte sedimentation rate. Symptoms of hyperthyroidism can remain for several weeks and may be followed by a 4-6 month period of hypothyroidism. Normal thyroid function generally restores within 12 months. Long-term thyroid replacement medication is required in 5% of patients.

Ampicillin (A) given parenterally may be an appropriate choice in suppurative thyroiditis. However, suppurative thyroiditis is distinguished from sub-acute thyroiditis by an elevated leukocyte count, which is not present in this patient. Levothyroxine (C) is the necessary treatment for hypothyroidism, not hyperthyroidism. Subacute thyroiditis usually allows of return of normal thyroid function within 12 months and levothyroxine is rarely needed. Methimazole (D) is a treatment option for hyperthyroidism, such as that caused by Graves disease. However, the hyperthyroidism of subacute thyroiditis will typically resolve spontaneously in 4-6 weeks; a beta-blocker is usually sufficient to manage these temporary hyperthyroidism symptoms.
Correct Answer ( C )
Explanation:

Pulmonary function tests should be monitored for patients on chronic amiodarone therapy. Amiodarone is a class III anti-arrhythmic drug used to treat many common dysrhythmias. Baseline pulmonary function tests and a chest radiograph with annual pulmonary function tests thereafter are recommended. Pulmonary toxicity generally correlates more closely with the total cumulative dose than the serum levels. It usually occurs months to years after initiation. Several types of pulmonary toxicity may result from chronic amiodarone therapy; however, the most common is a chronic interstitial pneumonitis. A non-productive cough and dyspnea are present in the majority of affected individuals. If signs or symptoms develop the patient should discontinue amiodarone immediately. Other complications of chronic amiodarone therapy include, but are not limited to, thyroid dysfunction, both hypo- and hyperthyroidism, symptomatic hepatitis, corneal microdeposits, optic neuropathy, or dermatologic manifestation such as photosensitivity and blue-gray skin discoloration. Thyroid function tests and hepatic panels are recommended every six months. Dermatologic physical exams and ophthalmologic eye evaluations are recommended as needed for signs or symptoms. These complications are treated by either reducing the dose and discontinuation.

Coagulation studies (A), complete blood counts (B) and renal panels (D) are not routinely monitored with amiodarone therapy; however, these studies are important for the monitoring of many different drugs. A few examples include coagulation studies for patients on warfarin, complete blood counts for patients on the antipsychotic, clozapine, and renal panels for patients on angiotensin converting enzyme inhibitors. These are just a few examples.
Correct Answer ( B )


There are two types of diabetes insipidus (DI), central and nephrogenic. The primary symptom of both types is the passage of large amounts of dilute urine. The posterior pituitary gland secretes antidiuretic hormone (ADH), which is the hormone involved in DI. Decreased secretion of ADH is characteristic of central DI. The majority of cases of central DI are idiopathic, although it may be caused by malignancy, neurosurgery or trauma. Patients with nephrogenic DI are unable to concentrate their urine because of resistance to ADH in the kidney. Nephrogenic DI can occur with lithium toxicity, renal disease, hypokalemia, hyperglycemia, pregnancy, and as a side effect of a number of other medications including amphotericin B, cidofovir, foscarnet and ofloxacin. Diagnosis of DI is confirmed through laboratory testing. Patients with suspected DI should have a 24-hour urine collection to assess urine volume, as well as serum electrolytes and glucose, urinary specific gravity, plasma and urine osmolality, and plasma ADH level. Treatment for central DI is fluid replacement and desmopressin. Patients may need hospitalization for monitoring and determination of fluid needs. Initial treatment for nephrogenic DI is a low-salt, low-protein diet, frequent voiding, and a thiazide diuretic. Patients taking lithium may have individualized treatment considerations.

Adrenocorticotropic hormone (A) is secreted from the anterior pituitary gland and stimulates the release of steroid hormones from the suprarenal gland. Glucagon (C) and insulin (D) are hormones secreted by the pancreas. Glucagon is produced by alpha cells and increases glycogen breakdown and glucose release in the liver. This process raises blood glucose levels. Insulin is produced by beta cells and lowers blood glucose levels. It is secreted in response to high blood glucose levels in the body and is the hormone involved in diabetes mellitus types 1 and 2.
Correct Answer ( D )
Explanation:

A mallet finger is caused by a forced flexion of the distal interphalangeal joint (DIP) leading to rupture of the extensor tendon at its insertion at the base of the distal phalanx or bony avulsion of the tendon insertion site. Appropriate treatment includes splinting the distal interphalangeal joint in full extension or slight hyperextension while allowing the proximal interphalangeal joint to have full range of motion. In untreated or under treated cases, a swan neck deformity occurs. Other causes include rheumatoid arthritis and connective tissue disorders (Ehlers-Danlos syndrome). A swan neck deformity is characterized by hyperextension of the proximal interphalangeal joint (PIP) and flexion of the distal interphalangeal joint (DIP).

Dupuytren's contracture (B) refers to a thickened and fibrous palmar fascia which is due to fibrous proliferation. It occurs commonly in men over age 40 years, but it also is common in those of Northern European descent, diabetics, alcoholics and epileptics. Boutonniere deformity (A) occurs from forced flexion at the proximal interphalangeal joint (PIP), causing a tear of the central portion of the extensor tendon at the proximal interphalangeal joint (PIP). Patients are unable to fully extend at the proximal interphalangeal joint (PIP) with the wrist and metacarpalphalangeal joints fully extended. Jersey finger (C) occurs in cases such as a football player grabs another player's jersey, avulsing the profundus tendon from its bony insertion.
Correct Answer ( C )
Explanation:

The patient has oral candidiasis, also known as thrush. Candidiasis is a mucocutaneous fungal infection that affects up to 80% of AIDS patients. Characteristic white plaques cover the tongue and buccal mucosa, which can be easily scraped off using a tongue blade. Although similar in appearance, the plaques associated with oral hairy leukoplakia cannot be scraped off, distinguishing it from oral candidiasis. Candida can also affect the esophagus, resulting in painful swallowing and ultimately malnutrition. Oral candidiasis is associated with CD4 counts below 500 cells/mm3 and esophageal candidiasis with more advanced disease (CD4 counts below 100 cells/mm3). Oral candidiasis is managed with clotrimazole or nystatin suspension. Oral fluconazole and amphotericin B are reserved for refractory or recurrent disease.

Herpes simplex virus infection (A), another cause of painful oral lesions, is characterized by vesicular lesions on the mucosal surfaces. Diagnosis is confirmed by identifying multinucleated giant cells in mucosal scrapings, PCR or culture. Kaposi sarcoma (B) is an AIDS-defining illness causing tumors on the skin, mouth, gastrointestinal tract, and respiratory tract. Oral Kaposi sarcoma appears as painless, well-circumscribed, raised, and violaceous lesions on the mucous membranes of the mouth. Biopsy is diagnostic. Oral hairy leukoplakia (D), caused by the Epstein-Barr virus (EBV), appears as white patches on the tongue, which cannot be scraped off.
Correct Answer ( D )
Explanation:

No bridging agent is necessary. Interruption of oral anticoagulation in patients with atrial fibrillation is sometimes necessary for invasive procedures, and it must be determined whether bridging is indicated. If the patient has a low short-term risk as determined by a CHA2DS2-VASc score of 0-1 and the duration of interruption is less than 1 week, then bridging is not needed. This patient has a CHA2DS2-VASc score of 1 due to his history of hypertension; therefore, no periprocedural bridging is necessary. In this scenario it would be recommended to simply discontinue warfarin approximately 5 days before the procedure with no bridging agent. Warfarin can often be resumed 12-24 hours after the procedure if there is no active bleeding.

If the patient has a high short-term risk with a CHA2DS2-VASc score of > 2, recent stroke, mechanical or rheumatic mitral valve or if the interruption is more than 1 week, then use of a bridging agent should be considered more strongly. In this setting, it would be appropriate to bridge with intravenous unfractionated heparin (B) or low molecular weight heparin (C). For atrial fibrillation patients with moderate risk features with a CHADS2 score of 3-4, a history of remote transient ischemic attack or stroke, or a mechanical aortic valve, management is individualized according to risks and benefits and is patient and provider dependent. It would not be appropriate to bridge with aspirin (A) as aspirin has no role in bridging.
Correct Answer ( D )
Explanation:

Bronchiolitis is a lower respiratory tract viral infection that is caused by damage of the epithelial cells lining the small airways, which leads to acute inflammation, increased mucous production, and bronchospasm. Bronchiolitis peaks between December and March. The clinical presentation includes rhinorrhea, cough, wheezing, low-grade fever, and shortness of breath. Bilateral wheezing and crackles are heard on pulmonary exam. Poor feeding and respiratory distress (tachypnea, nasal flaring, and hypoxemia) are indicators of increased severity. Oxygen saturation less than 95 percent, PO2 less than 65, PCO2 greater than 40, atelectasis on chest X-ray, and respiratory rate greater than 70 are also all indicators of severe disease. Bronchiolitis most commonly occurs between two and seven months of age, but can occur in those up to two years old. The most common virus associated with bronchiolitis is respiratory syncytial virus (RSV). Other causes include parainfluenza virus, metapneumovirus, and adenovirus. Symptoms can last up to five days and generally worsen by day three before subsiding. Most patients can undergo observation and supportive care. Treatment is symptomatic and includes cool mist. Hospitalization is determined by the patient's comorbidities, reliability of parents, duration of symptoms, and condition on presentation (hypoxia, tachypnea, dehydration, age).


Racemic epinephrine (A) is the treatment for laryngotracheobronchitis (croup) caused by parainfluenza virus and is characterized by a barking cough and inspiratory stridor. Bronchodilators (B), such as albuterol, are not routinely given when managing bronchiolitis. Bronchiolitis is usually a clinical diagnosis, and a chest X-ray (C) is not required to make the diagnosis. Chest X-ray findings typically include hyperinflation and patchy infiltrates. Focal findings are not consistent with bronchiolitis.
Correct Answer ( C )
Explanation:

This patient presents with anaphylactic shock from an insect bite and requires immediate administration of epinephrine. Epinephrine is potentially life-saving in severe anaphylactic reactions. During an anaphylactic reaction, mast cells degranulate leading to release of histamines and other immune mediators. These mediators lead to the hallmark symptoms of allergic reactions including hives, nausea and vomiting, airway edema, bronchoconstriction and hypotension. Epinephrine acts immediately on adrenergic receptors to reverse these symptoms. Inhaled beta agonists can also be given to rapidly reverse bronchoconstriction. Many of the other treatments in anaphylaxis have a delayed onset of action. Diphenhydramine (H1 receptor blocker) acts by blocking the effect of histamine on H1 receptors mainly in the skin. Ranitidine, famotidine and other H2 blockers can mitigate some of the gastrointestinal symptoms caused by histamine as well as some of the cutaneous manifestations. Steroids mainly act by stabilizing mast cells from further degranulation but this effect is usually delayed 4-6 hours after administration. Steroids also increase the expression of beta-receptors in the lung increasing the efficacy of inhaled beta-agonists. Epinephrine should be given as 300 - 500 mcg IM in the anterolateral thigh. This dose equates to 0.3 - 0.5 mL of the 1:1000 preparation.

Giving epinephrine 1:1000, 0.3 mL IV (D) is a massive overdose and can cause dysrhythmias and cardiac ischemia. Cardiac epinephrine (A & B) (1:10,000 concentration) comes in vials of 10 mL for a total of 1000 mcg of epinephrine. This preparation of epinephrine is reserved for use in patients with cardiac arrest (ventricular fibrillation, pulseless electrical activity or asystole) and should not be given to patients with a blood pressure. 0.3 mL of cardiac epinephrine IM is a 10-fold underdose as this amount only contains 30 mcg of epinephrine.
Correct Answer ( D )
Explanation:

A Tinel test is considered positive when percussion of the volar wrist in the region of the median nerve produces tingling or a shock-like pain in the palmar surfaces of digits 1-3. This test is generally sensitive for clinically diagnosing carpal tunnel syndrome, an entrapment neuropathy due to some form of compression or narrowing of the carpal tunnel that impinges the median nerve. Other physical exam findings may include a positive Phalen sign in which flexion of both wrists to 90 degrees for one minute causes pain or tingling in the median nerve distribution. The carpal compression test, in which the clinician applies steady, direct pressure over the carpal tunnel to elicit tingling, may be even more sensitive for the condition. Carpal tunnel syndrome generally presents with pain and tingling in the median nerve distribution and may initially bother the patient only during sleep. A history of performing repetitive activities may be noted. Diabetes mellitus and fluid retention during pregnancy can also contribute to carpal tunnel compression. A work-up for carpal tunnel syndrome may include an ultrasound to observe flattening of the median nerve, or electromyography and nerve conduction studies to differentiate it from a more proximal neuropathy. A trial of wrist extension splinting, as well as NSAIDs and corticosteroids, may help. Surgical carpal tunnel release can be considered for symptoms beyond 12 months of conservative treatment.

A Finkelstein test (A) requires sharp, ulnar deviation of the thumb while the fingers are flexed around the thumb into a fist. Pain at the wrist is suggestive of deQuervain tenosynovitis. A Phalen test (B) is positive when flexion of both wrists to 90 degrees for one minute causes pain or tingling in the median nerve distribution. Like A Tinel test, a positive Phalen test suggests carpal tunnel syndrome. A Spurling test (C) requires the patient to rotate and extend the neck to one side while the clinician gently applies an axial load to the neck. Nerve root compression is likely when this test produces cervical radiculopathy.
Correct Answer ( B )
Explanation:

Aortic stenosis increases afterload to the left ventricle resulting in concentric left ventricular hypertrophy. Pressure overload leads to concentric left ventricular remodeling with or without an overall increase in myocardial mass. Concentric remodeling is characterized by increased relative wall thickness or ventricular wall thickness as compared to cavity size. With concentric hypertrophy, cardiac sarcomeres are added in parallel and individual cardiomyocytes grow thicker. This pattern of hypertrophy is adaptive to the increased wall stress of the left ventricle and helps maintain normal systolic function of the left ventricle. However, as severity of stenosis and left ventricular remodeling progresses, abnormal diastolic function typically occurs. This usually precedes systolic dysfunction and results in increased left ventricular filling pressures and symptoms of angina and dyspnea. In contrast, pure regurgitant lesions, such as mitral valve regurgitation cause volume overload to the left ventricle. The remodeling pattern involves eccentric left ventricular hypertrophy; a compensatory mechanism that maintains ventricular compliance. This allows increased left ventricular volume without increased left ventricular filling pressure. With progression of regurgitation and left ventricular dilation, left ventricular contractility or systolic function is impaired. Patients with mixed stenotic and regurgitant lesions such as combined aortic stenosis and regurgitation, may develop concentric and eccentric hypertrophy. In this scenario the dominant lesion determines left ventricular remodeling, clinical presentation, and management.

Eccentric left ventricular hypertrophy (C) is characterized by increased cardiac mass and chamber volume and is caused by volume overload or isotonic exercise. Relative wall thickness may be normal, increased, or decreased. With eccentric hypertrophy, sarcomeres are added in series and individual cardiomyocytes grow longer. This pattern of left ventricular remodeling is not seen in aortic stenosis. Mixed concentric/eccentric left ventricular hypertrophy (D) can occur in mixed stenotic and regurgitant lesions or following myocardial infarction. Myocardial infarction causes stretched, infarcted tissue which increases left ventricular volume, leading to combined volume and pressure load on noninfarcted zones. Asymmetric left ventricular hypertrophy (A) is typical of hypertrophic cardiomyopathy and is not associated with aortic stenosis.
Correct Answer ( D )
Explanation:

This patient has Guillain-Barré syndrome (GBS), an immune-mediated peripheral neuropathy caused by myelin sheath destruction. It is often preceded by a viral illness, infection with Campylobacter jejuni, or vaccination. In the classic presentation of GBS, a viral illness is followed by an ascending symmetric weakness or paralysis with decreased or absent deep tendon reflexes. The most serious complication of GBS is respiratory failure from diaphragmatic weakness. Measuring the vital capacity or negative inspiratory force (NIF) is critical to assessing respiratory effort. These easily repeated tests predict developing diaphragmatic weakness and the need for prophylactic intubation. GBS is treated with supportive care, IV immune globulin, and possibly plasmapheresis. All patients with suspected GBS should be admitted to an intensive care unit.

Electromyelography (A) (EMG) measures the action potential of a nerve and its muscle unit and provides information on the innervation status of a muscle, less likely to be abnormal in acute demyelination without axonal loss. EMG readings will show slowed action potentials in GBS because of demyelination. Although it is useful to distinguish a neuropathic etiology of weakness, it is not diagnostic of GBS, nor does it predict potential complications such as respiratory failure. Lumbar puncture (B) is sometimes performed to augment the diagnosis of GBS, but is not the test of choice; it has no predictive value. CSF will often show few WBCs, with a monocytic predominance and increased protein. Although MRI (C) of the lumbar spine may be performed to rule out a cord-compressing, space-occupying lesion that could be causing bilateral weakness, it provides no other specific information and will be negative in cases of GBS.
Correct Answer ( C )
Explanation:

Prinzmetal angina, or variant angina, is the most likely diagnosis in this patient. Prinzmetal angina is characterized by spontaneous episodes of angina in association with ST-segment elevation on ECG. The cause is a transient, abrupt, and marked reduction in the luminal diameter of an epicardial coronary artery due to spasm which leads to transient myocardial ischemia. Unlike most other causes of chest pain and ST-segment elevation, the ST-segment returns to baseline rapidly upon resolution of symptoms. This is a diagnosis of exclusion. Patients with variant angina are often younger and exhibit fewer classic cardiovascular risk factors, with the exception of cigarette smoking. Variant angina may be associated with other vasospastic disorders such as Raynaud's phenomenon and migraine headache or its treatment, such as sumitriptan. A history of drug abuse, such as cocaine, may also be present.


Costochondritis (A) is musculoskeletal chest wall pain that causes more diffuse pain, in which multiple areas of tenderness are found and can usually be reproduced with palpation. Panic disorder (B) is a particularly common cause of chest pain; however it is not associated with ECG changes and is less consistent with this clinical picture. Unstable angina (D) is a presentation of acute coronary syndrome characterized by new, worsening or persistent chest pain, but in the absence of positive cardiac biomarkers. This can be difficult to distinguish from Prinzmetal angina; however, it would be less likely in a younger patient and it is not associated with other vasospastic disorders such as migraine headaches or Raynaud's phenomenon.
Correct Answer ( D )
Explanation:

This patient presents with a unilateral, subacute headache with associated jaw claudication and vision change; symptoms consistent with temporal arteritis. Temporal arteritis or giant cell arteritis is a systemic inflammatory process of small and medium-size arteries. The most commonly involved vessels are the ophthalmic vessels and the extracranial branches of the aortic arch. The disease typically affects patients over 70 years of age and is more common in women than in men. Patients present with a subacute headache that is throbbing in nature and may be present for weeks to months. Often, patients will have symptoms for more than 2 months. Patients may also report jaw claudication secondary to vascular insufficiency of the masseter and temporalis muscles. Physical examination may reveal tenderness over the temporal artery. Systemic symptoms may also be present including fever, joint pains, and weight loss. Diagnostic testing in the Emergency Department generally begins with an erythrocyte sedimentation rate (ESR) with a cutoff of 50 mm/hour although the level may be >100 mm/hour. However, the ESR will be normal in 10-25% of patients. The gold standard diagnostic test is a temporal artery biopsy. In patients with a high-clinical likelihood of temporal arteritis, treatment should be initiated regardless of initial diagnostic testing as delay can lead to permanent visual loss. Prednisone should be started at 60 - 120 mg/day.

Carbamazepine (A) is the treatment of choice for trigeminal neuralgia, not temporal arteritis. The patient does not present with symptoms consistent with hypertensive emergency requiring emergent antihypertensive treatment with labetalol (B). A non-contrast head CT scan (C) is not helpful in temporal arteritis as the disease does not involve the intracranial contents.
Correct Answer ( D )
Explanation:

Infiltrative myocardial deposition usually results in restrictive cardiomyopathy (RCM). Evaluation begins with the typical heart failure work-up of chest radiograph, ECG, echocardiogram, cardiac MRI and possibly cardiac catheterization. A chest radiograph may show enlarged atria and normal ventricles. ECG may reveal low voltages and tachyarrhythmias. Echocardiographic findings typical of RCM include bilateral atrial enlargement, normal or thickened ventricular walls, decreased right > left ventricular walls, mural thrombi and diastolic dysfunction. A cardiac MRI may show myocardial inflammation or infiltrates. Endocardial biopsy may be necessary to confirm a diagnosis. Treatment of RCM is difficult due to the relative refractoriness of many of the underlying pathologies. Specific augmentative treatments are aimed at the underlying disorder. One example is corticosteroids, like prednisone or prednisolone, used to control sarcoidosis and Loeffler's endocarditis. Gentle diuresis may be helpful. Anticoagulation is usually considered.

Serotonin agonists are contraindicated in patients with restrictive cardiomyopathy, as these drugs, like buspirone (A), cisapride and sumatriptan, can cause decreased compliance of the endomyocardium, and actually lead to restrictive cardiomyopathy. Chemotherapy, like melphalan (B) and cyclophosphamide, is used to decrease the amount of abnormal cells in amyloid restrictive cardiomyopathy. Phlebotomy (C) and chelation therapy are used to control the complications of hemochromatosis.
Correct Answer ( C )
Explanation:

Sudden cardiac death is a leading cause of mortality. It occurs in a bimodal age distribution: infancy and individuals > 45 years or age. There is a slight predominance in men. In a sudden episode of cardiac death, the initial rhythm is most likely ventricular fibrillation, or ventricular tachycardia that degenerates into ventricular fibrillation. In a witnessed cardiac arrest, if the initial rhythm is amenable to defibrillation, a shock should be administered as soon as possible. Defibrillation is the best chance of recovering a perfusing rhythm from a nonperfusing rhythm. The longer a heart is in a nonperfusing rhythm, the less likely it is to respond to defibrillation and cardiac life support.

Two minutes of chest compressions (D) is the standard cycle length for chest compressions. In the unwitnessed cardiac arrest, two minutes of chest compression should be initiated to "prime" the heart to receive defibrillation. However, in a witnessed arrest an immediate shock should take precedence. Administration of amiodarone (A) is a pharmacologic attempt to achieve a stable cardiac rhythm. It is indicated for persistent pulseless ventricular tachycardia or ventricular fibrillation after defibrillation and epinephrine have not resulted in a perfusing cardiac rhythm. Cardioversion (B) is indicated in an unstable (but not pulseless) cardiac rhythm (e.g. atrial fibrillation with rapid ventricular response) in an attempt to recover a normal sinus rhythm for the patient. Cardioversion does not play a role in the pulseless patient.
Correct Answer ( C )
Explanation:

The patient has otitis externa. Otitis externa refers to infection and inflammation of the external ear. Factors which predispose to otitis externa include local trauma (often from scratching or attempted cerumen removal) and elevation of the local pH (frequent contact with water from swimming in pools or freshwater lakes). The most common organisms causing otitis externa are Pseudomonas aeruginosa, Staphylococcus aureus, Enterobacteriaceae, and Proteus species. Fungal species (like Aspergillus and Candida) cause otomycosis and are seen in immunosuppressed hosts, those with recent long-term antibiotic therapy, or in hot humid climates. The clinical presentation of otitis externa includes pruritus, pain, erythema, edema, and tenderness of the external auditory canal. Clear or purulent otorrhea may be present and crusting on the external canal is common. Infection may spread to the tragus, auricle, and periauricular soft tissues. Local lymph nodes may be inflamed. The treatment for otitis externa includes analgesia, cleansing of the external canal, and topical antimicrobials with or without steroids. Non-ototoxic topical antibiotics should be selected, particularly if swelling interferes with middle ear visualization and tympanic membrane rupture cannot be excluded. If edema of the external canal obstructs the lumen, an ear wick should be used to enhance distal delivery of the topical drops. Systemic antibiotics are not usually indicated, unless fever or periauricular extension is present.



Aspergillus (A) and other fungal causes of otitis externa are usually seen in the immunocompromised or those with previous long-term antibiotic therapy. Moraxella catarrhalis (B) and Streptococcus pneumonia (D) are common causes of otitis media, not otitis externa.
Correct Answer ( B )
Explanation:

Rheumatoid arthritis (RA) is treated with a variety of medications, from salicylates to disease-modifying anti-rheumatic drugs (DMARDs). Several, if not all, of these medications carry significant side effects and toxicities. As such, routine monitoring of potential side effects or pathology is recommended and necessary. Common side effects of these medications include nausea, vomiting, diarrhea and rash. However, one of the most common DMARD adverse events is bone marrow suppression, especially with sulfasalazine, methotrexate, gold preparations, leflunomide, cyclosporine and azathioprine. Therefore, it is important to monitor marrow health with serial complete blood counts. Hepatitis and hepatic toxicity can occur with chronic methotrexate and leflunomide. As such, clinicians should obtain liver function tests at baseline and periodically throughout treatment. Leflunomide and cyclosporine are associated with hypertension. As such, routine monitoring of blood pressure is important in patients on these medications. Gold preparations are associated with significant kidney damage, namely proteinuria. It is recommended to check serial urinalyses, even on a weekly basis, in patients taking gold sodium thiomalate. Checking a PPD test for tuberculosis is also recommended.

Repeated chest X-rays (A) are not routinely recommended in monitoring the effects of DMARD medications. Rheumatoid factor (C) is not a very sensitive or specific marker of rheumatoid arthritis. However, a screen for this antibody is routinely performed, but commonly negative (especially in early disease), to help secure a diagnosis of RA, not monitor for DMARD side effects. Eventually, nearly 70-80% of patients with RA will have a positive RF. DMARDs are not commonly associated with thyroid disease (D).
Correct Answer ( D )
Explanation:

Smooth, firm enlargement of the prostate gland is characteristic of benign prostatic hyperplasia (BPH). BPH is the most common benign tumor in men, with the incidence estimated at 50% of men by 60 years. Between ages 55-75, the likelihood of developing obstructive voiding symptoms rises significantly. Symptoms include hesitancy and straining to urinate, decreased force and caliber of the urine stream, and the need to urinate twice within 2 hours due to incomplete emptying. Post void dribbling can occur due to the residual urine in the bladder after voiding. Men may also develop irritative bladder symptoms including urgency, frequency, and nocturia. Though prostate size does not correlate with symptoms, a rectal exam will usually show some degree of smooth, firm enlargement. Induration should not be present, as this would be more concerning for malignancy. A distended bladder may be palpated. The decision to get a serum prostate-specific antigen level is controversial, as it is difficult to use this value to determine whether a patient has BPH as opposed to cancer. The American Urological Association symptoms index should be used to gauge severity of BPH and guide treatment. Recurrent urinary tract infections, gross hematuria, bladder stones, or kidney disease merit surgical resection and require referral to urology. Otherwise, mild symptoms can be managed with observation. Moderate to severe symptoms merit medical therapy, for which many options exist. Alpha-blockers will reduce symptoms by improving urine flow at the bladder neck. The 5-alpha reductase inhibitors, interrupts the processing of testosterone and can actually decrease the size of the prostate and improve symptoms. Six months are required to see improvement. Phosphodiesterase-5 inhibitors, like tadalafil, can offer improvement as well. Combination therapy is usually beneficial and tolerated.



Asymmetric enlargement of the prostate gland with unilateral induration (B) is concerning for prostate cancer. This finding should alert the clinician to the need for further work-up, including a serum prostate-specific antigen, transrectal ultrasound, and biopsy. A warm, boggy prostate gland that is tender on palpation (A) is a typical finding in acute or chronic bacterial prostatitis. In the acute setting, this requires a urine culture with antibiotics guided by culture findings. A normal size and texture of the prostate gland (C) may occasionally be present in patients with underlying BPH. However, a normal prostate exam should alert the clinician to explore other causes of the obstructive and irritative voiding symptoms, such as urinary tract infections, urethral strictures, or neurogenic bladder.
Correct Answer ( C )
Explanation:

Commonly a complication of otitis media, upper respiratory infection or meningitis, labyrinthitis is an abnormality of the inner ear vestibular system, which consists of three semicircular canals, vestibule, utricle and sacule. When the vestibular system is damaged, injured or inflamed, balance deficits and vertigo arise. However, since an anatomic connection between the vestibular system and cochlea exist, tinnitus and hearing impairment also occur. The classic clinical picture of labyrinthitis is acute, profound, incapacitating vertigo, with nausea, vomiting and nystagmus. Tinnitus and hearing impairment usually accompany the onset of vertigo. These symptoms resemble those of Meniere's disease, however in Meniere's disease, symptoms are intermittent and possibly less severe. Furthermore, the pathology is different between the two conditions. Labyrinthitis is mainly due to inflammation, while an excess of inner ear fluid causes Meniere's disease. Treatment of suspected viral labyrinthitis includes bed rest, hydration, antiemetics and vestibular depressants. Treatment with corticosteroids during the acute period of vertigo has been shown to improve the recovery of peripheral vestibular function in patients with acute labyrinthitis. Benzodiazepines are also effective.



Currently, the role of antiviral therapy, like acyclovir (A), in the treatment of labyrinthitis is not established. Studies to date do not show an improvement over placebo. Phentermine (B) is used as an appetite suppressant and plays no role in the treatment of labyrinthitis. Prochlorperazine (D), an antiemetic, is commonly used in the treatment of acute viral labyrinthitis. Its dopamine-antagonism and anticholinergic effects help relieve nausea and vomiting, but do not diminish the distressing sensation of vertigo.
Correct Answer ( C )
Explanation:

Dermal melanosis, also known as a Mongolian spot, represents a benign persistence of dermal melanocytes in neonates. It presents as large blue patches that are most commonly located over the sacrum and shoulders. Rarely, the face and flexor surfaces of the extremities may be involved. It is more common amongst all non-Caucasian races. The natural history of dermal melanosis is a gradual fade during the first two years of life. Most lesions resolve completely during grade school. Extra-sacral locations are more likely to persist into adulthood. Persistent lesions remain benign, and no treatment is indicated.



Child abuse (A) should be suspected in any infant with significant bruising in unusual locations, as well as in any child who does not walk ("those who don't cruise, don't bruise.") However, the distribution and description of this child's blue patches are consistent with dermal melanosis rather than child abuse. Coagulopathy (B) is a consideration in any child with unusual ecchymoses, purpura, petechiae, or bleeding. However, this infant's bluish discoloration over the sacrum and shoulders are consistent with dermal melanosis rather than true bruising. Nevus of Ota (D) is a rare dermal melanocytosis that preferentially involves the distribution of the first two trigeminal nerves. In contrast to dermal melanosis, its appearance is speckled or mottled and may be grey or blue-black in color. Underlying CNS melanosis or ocular melanoma may also occur, necessitating yearly ophthalmologic examination.
Correct Answer ( C )
Explanation:

Shigella species cause an invasive diarrhea that rarely infects infants younger than three months old and is most common between two and three years of age. Infection is typically transmitted by person-to-person (fecal-oral) contact or through ingestion of contaminated material. Clinical illness varies from mild to severe, with some patients exhibiting abdominal cramps and tenderness. Dysentery (diarrhea with significant blood, pus, and mucus) occurs in approximately 33% of patients. Some patients may also develop extraintestinal manifestations such as reactive arthritis, seizures, and hallucinations.



Although antibiotics (A) are generally not indicated for the treatment of mild illness, they should be considered in more severe cases. Hemolytic uremic syndrome (HUS) is a potentially fatal complication that develops when antibiotics are administered to children (but not adults) with enterohemorrhagic E. coli (O157.H7). HUS results from the release of Shigella-like toxin by dying E. coli (not Shigella itself as which occurs from Shiga toxin). For this reason, it is recommended that empiric antibiotic therapy be held in pediatric patients with infectious diarrhea pending culture results. In this case, the causative organism is already known, and antibiotic therapy can be safely administered. Antidiarrheal agents (B) are not recommended because they can worsen bacterial invasion of the bowel wall and prolong the infection and carrier state. If dehydration is a concern, oral rehydration (D) should be attempted prior to initiating IV fluids because the patient is not vomiting and is able to tolerate oral intake.
Correct Answer ( A )
Explanation:

24-48 hour continuous ambulatory ECG monitor, also known as a Holter-monitor, is the most appropriate next step in management. It is one of the most frequently used and cost-effective noninvasive tests used to evaluate cardiac rhythm abnormalities. The clinical utility of the ambulatory ECG recording lies in its ability to continuously examine the patient's cardiac rhythm over an extended period of time during normal routine activity, including any physical and psychological changes. Various rhythm recorders can be used to capture a dysrhythmia. Selection depends on the frequency and duration of symptoms. A Holter monitor is worn for 24-48 hours and is used for evaluation of more frequent symptoms. This patients symptoms occur daily, so a 24-48 hour monitor is likely to capture a possible dysrhythmia during an episode of palpitations or pre-syncope.



Several other options to monitor cardiac rhythm abnormalities exist and include event recorders and implantable loop recorders. These monitors are most useful when symptoms are infrequent. A post-symptom event recorder (D) is held to the chest when symptoms occur. The advantage of a post-symptom recorder is the lack of electrode leads, making it more comfortable to carry. Implantable loop recorders (C) allow for continuous ECG monitoring to detect cardiac arrhythmias over months to years. This device is placed subcutaneously, similar to a pacemaker, and can be interrogated non-invasively. A looping event recorder records several seconds of the rhythm prior to the device being triggered and is useful in patients with syncope who many not be able to trigger the recording device. This patient's symptoms are frequent making these devices unnecessary. Electrophysiologic testing (B) is invasive and reserved for those at risk of sudden cardiac death. It is indicated in select, high risk patients with unexplained syncope, particularly those with structural heart disease. Electrophysiologic testing should be considered when noninvasive tests have failed to make a diagnosis. This patient is not likely to have structural heart disease or be at risk for sudden cardiac death based upon her history, physical exam findings and initial testing.
Correct Answer ( D )
Explanation:

Valve disorders are often characterized in terms of stenosis (incomplete opening of the valve, thereby increasing the resistance in blood flow) or regurgitation (an incomplete closure of a valve, resulting in a backflow of blood). The tricuspid valve is 1 of 2 atrioventricular (AV) valves and lies between the right atrium and right ventricle. In tricuspid regurgitation, there is incomplete forward flow from the right atrium into the right ventricle and blood flows from the right ventricle into the right atrium during systole. This backflow of blood results in increased right atrial pressure. Tricuspid regurgitation is caused by right ventricular dilation secondary to pulmonary hypertension, rheumatic heart disease, and infective endocarditis. Patients may complain of fatigue and dyspnea on exertion. On exam, there may be a holosystolic murmur best heard at the xiphoid area adjacent to the left sternal border.



The aortic valve is one of 2 semilunar valves (the other being the pulmonary valve) and is positioned between the left ventricle and aortic trunk. Aortic regurgitation (A) results in a backflow of blood and an increase in pressure of left ventricle during diastole. The mitral valve is the 2nd AV valve and is situated between the left atria and left ventricle. Mitral regurgitation (B) causes a backflow into the left atria during systole, increasing left atrial pressure. In mitral stenosis (C), the mitral valve cannot fully open during diastole, resulting in an increase in resistance in blood flow through the valve and increasing the left atrial pressure while decreasing the filling of the left ventricle.
Correct Answer ( B )
Explanation:

A hydrogen breath test is the most commonly used test to diagnose lactase deficiency leading to lactose intolerance. Lactose intolerance is a very common condition worldwide, as most people of non-European heritage experience a reduction in the concentration of their lactase enzymes during childhood that continues to progress into adulthood. This results in varying manifestations of gastrointestinal distress when patients are presented with dairy products. While some patients may be able to tolerate a small quantity of lactose-containing products if consumed with other foods, others require complete avoidance to remain distress-free. Patients may complain of diarrhea, bloating, cramping abdominal pain, and flatulence after eating lactose products. However, signs of nutrient malabsorption, systemic illness, or weight loss should not occur with isolated lactose intolerance. These findings should alert clinicians to assess for other gastrointestinal disorders. If a hydrogen breath test results in a rise of breath hydrogen beyond baseline after consuming 50 grams of lactose, lactose intolerance is likely. Two week of abstaining from any lactose-containing products should then be recommended. Resolution of symptoms during that time is confirmative of lactose intolerance. At that point, patients should be counseled to seek replacements for the calcium generally found in dairy products to prevent osteoporosis. Lactase-containing preparations may be beneficial.



A colonoscopy (A) does not help in diagnosing lactose intolerance, the most likely disorder in this patient. It would be more helpful if weight loss, tenesmus, or bloody stools were present to indicate an underlying malignancy or inflammatory bowel disorder needing structural assessment. An IgA endomysial antibody test (C), along with an IgA tissue transglutaminase antibody test, is considered a very sensitive and specific test to diagnose Celiac disease. However, this patients symptoms relative to dairy consumption made Celiac disease a comparably less-likely causative condition. A qualitative fecal fat assay (D) is valuable in patients suspected of conditions for which steatorrhea is a presenting symptom. Steatorrhea was not observed in this patient's history.
Correct Answer ( B )
Explanation:

Hypertensive emergency is generally defined as a markedly elevated blood pressure in the setting of acute end-organ damage of the cardiovascular, neurologic, or renal organ system. This condition is a true medical emergency and warrants early reduction of blood pressure (preferably within one hour of identification of the condition) with titratable intravenous medications. It is important to understand, however, that an elevated blood pressure in response to an acute condition is often physiologic; aggressive lowering of the pressure in these conditions (e.g., ischemic stroke) may actually increase morbidity and mortality. Renal failure can be seen as both a consequence and cause of hypertension. Uncontrolled hypertension may cause acute kidney injury and can accelerate the progression of injury in patients with chronic renal failure. Acute worsening of kidney function as seen in this patient whose creatinine increased acutely from 1 to 2.5 mg/dL—in the setting of elevated blood pressure—should be considered a hypertensive emergency and warrants immediate treatment.



Hypertension is one of the most common complications in pregnancy. Hypertension in pregnancy is defined as a systolic pressure > 140 mm Hg or a diastolic pressure > 90 mm Hg. Severe hypertension is classified as a systolic pressure > 160 mm Hg or diastolic > 105 mm Hg. Pre-eclampsia is defined as hypertension occurring after 20 weeks gestation with proteinuria or any signs or symptoms of end-organ damage (e.g., elevated LFTs) and should be considered a hypertensive emergency. Hypertension occurring after 20 weeks gestation without these signs or symptoms (A) is termed gestational hypertension. Patients who are hypertensive, but asymptomatic, and show no evidence of acute end-organ damage (C and D) in most cases, do not need acute lowering of their blood pressure. Patients with chronic hypertension may have an altered autoregulatory range; rapid normalization of their elevated blood pressure may in fact lead to hypoperfusion and ischemia. In response to chronic hypertension, the heart is remodeled in a cycle starting with increased wall stress that leads to hypertrophy and impaired diastolic function. When LVH is present in the setting of hypertension, early follow-up should be arranged because such patients are at increased risk for MI, heart failure, stroke, and sudden death.
Correct Answer ( B )
Explanation:

No additional testing is indicated in this patient. She most likely has a benign systolic ejection murmur. This is a common clinical situation and reassurance is appropriate. A systolic murmur is present in up to 60 % of patients, with 90 % being associated with a normal echocardiogram. A murmur is characterized by its intensity or grade, timing, configuration, frequency or pitch, and location. The most common causes of a mid-systolic murmur are innocent flow murmurs, an increase in flow rate across a normal semilunar valve, and aortic valve sclerosis. Innocent murmurs are typically systolic ejection murmurs located at the base of the heart, short and soft, grade 1/6 to 2/6, without radiation, with a normal S1 and S2, normal cardiac impulse, and no evidence of any hemodynamic abnormality. The benign characteristics of the murmur in this patient include a grade < 3/6, mid-systolic timing, lack of radiation, and the absence of additional abnormal heart sounds. The remainder of the physical examination and the electrocardiogram are normal, without any evidence of cardiac enlargement or dysfunction. Signs of more serious cardiac disease include an S4, grade >3/6 intensity, any diastolic murmur and fixed splitting of S2.

Transthoracic echocardiography (D) is the primary test for diagnosis and assessment of valvular heart disease. The appropriateness of this test is guided by history and physical examination. It is indicated in symptomatic patients, in those with a systolic murmur grade 3/6 or greater, diastolic murmurs, continuous murmurs (begins after s1 and beyond s2), holosystolic murmurs, late systolic murmurs, murmurs associated with ejection clicks, or murmurs that radiate to the neck or back. This patient's murmur does not have any of these characteristics. Transesophageal echocardiography (C) may be useful in patients with poor imaging by transthoracic study or to evaluate the feasibility of surgical repair when surgery is planned. Cardiac magnetic resonance imaging (A) is indicated if both transthoracic and transesophageal echocardiograms are equivocal in a more suspicious murmur. It is good for the assessment of the aorta and cardiac chamber size and function.
Correct Answer ( B )
Explanation:

Arterial embolism can be divided into thromboembolic and atheroembolic causes. Most arterial thromboemboli originate in the left side of the heart and are frequently associated with a recent myocardial infarction, atrial fibrillation, or valvular abnormalities. Acute arterial thromboembolism results in the sudden loss of a previously present pulse. In general, patients with arterial thromboembolism have few physical findings suggestive of long-standing peripheral vascular disease and will have normal proximal and contralateral limb pulses. These patients typically do not have well-developed collateral circulation and are at high risk for limb ischemia.



Arterial atheroemboli (A) refers to microemboli consisting of cholesterol, calcium, and platelet aggregates dislodged from proximal complicated atherosclerotic plaques. In the peripheral vascular system, atheroemboli characteristically present with cool, painful, and cyanotic toes ("blue-toe" syndrome). Arterial thrombosis (C) is a chronic condition associated with progressive development of complicated atherosclerotic plaques. Peripheral arterial thrombi are usually firmly attached to the damaged arterial wall and rarely embolize. Patients will exhibit signs of longstanding atherosclerosis in their lower extremities (atrophy, loss of hair growth, thickened toe nails) and often have a history of claudication. These patients have well-developed collateral circulation, which helps protect them from limb-threatening ischemia. Arterial vasospasm (D), such as Raynaud's disease, causes a sharp border between ischemic and normal tissue. This condition is characterized by intermittent attacks of triphasic color changes (pallor, cyanosis, rubor).
Correct Answer ( C )
Explanation:

Tension-type headaches cause pain that is mild or moderately intense and is described as tightness, pressure, or a dull ache. The pain is usually experienced as a band extending bilaterally back from the forehead across the sides of the head to the occiput. Patients often report that this tension radiates from the occiput to the posterior neck muscles. In its most extensive form, the pain distribution is "cape like," radiating along the medial and lateral trapezius muscles covering the shoulders. Tension-type headaches can last from 30 minutes to several days and can be continuous in severe cases. In addition to its characteristic distribution and intermittent nature, the history obtained from patients with tension-type headache discloses an absence of signs of any serious underlying condition. Patients with tension-type headache do not typically report any visual disturbance, fever, stiff neck or recent trauma. Treatment goals for patients with tension-type headache should include recommending effective over the counter analgesic agents and discovering and ameliorating any circumstances that may be triggering the headaches. Research confirms that NSAIDs, such as Ibuprofen, and acetaminophen are effective in reducing headache symptoms. Patients with chronic tension-type headache should limit their use of analgesics to two times weekly to prevent the development of chronic daily headache. Repeated use of analgesics, especially ones containing caffeine or butalbital, can lead to "rebound" headaches as each dose wears off and patients then take another round of medication. Common features of chronic daily headache associated with frequent analgesic use are early morning awakening with headache, poor appetite, nausea, restlessness, irritability, memory or concentration problems, and depression. If the patient requires analgesic medication more frequently, adjunctive headache medications can be initiated. Smoking cessation is an important issue to address in patients with chronic tension-type headache. The number of cigarettes smoked has been "significantly related" to the headache index score and to the number of days with headache each week.



Analgesics can be augmented with a sedating antihistamine, such as promethazine (D) and diphenhydramine or an antiemetic, such as metoclopramide and prochlorperazine. If this regimen is inadequate, the patient can try acetaminophen or aspirin combined with caffeine (B) and butalbital. A wide variety of prophylactic agents have been researched in the management of chronic tension-type headache. Amitriptyline (A) is the most researched of the prophylactic agents for chronic tension-type headache. It is typically used in doses of 10 to 75 mg, one to two hours before bedtime to minimize grogginess on awakening.
Correct Answer ( C )
Explanation:

In order to fully understand the different syndromes of injuries to the spinal cord, it is imperative to understand the location of the tracts of the cord. The posterior columns carry tracts responsible for ipsilateral position and vibratory sensation. The lateral spinothalamic tract carries fibers for contralateral pain and temperature. The lateral corticospinal tract is responsible for ipsilateral motor function. Syndromes may be incomplete depending on how much of the cord is affected by the injury. In the anterior spinal cord syndrome, just the posterior columns are preserved and so patients lose all pain and temperature sensation as well as motor function. Most cases of anterior cord syndrome follow aortic surgery, but it has also been reported in the setting of hypotension, infection, vasospasm, or anterior spinal artery ischemia or infarct. In trauma, typically hyperflexion of the cervical spine causes the injury to the spinal cord.



Loss of all motor and sensory function (B) occurs with a complete transection of the spinal cord. Most commonly this occurs after a significant trauma. Isolated motor function loss (A) is not a classic syndrome and would result from a small area of injury on the cord just involving the corticospinal tract. Upper greater than lower motor weakness occurs (D) with a central cord syndrome. Sensory involvement is variable although burning dysesthesias in the upper extremities may occur. Most commonly the syndrome occurs after a fall or motor vehicle accident. Anterior cord may also be known as ventral cord syndrome.
Correct Answer ( B )
Explanation:

The above patient's constellation of fever, cough, and focal lung findings are concerning for community-acquired pneumonia. The onset of symptoms was acute and severe, and the lung findings are focal, which is suggestive of a typical bacterial etiology. S. pneumoniae is the most frequent cause of "typical" bacterial pneumonia in children of all ages. However, in otherwise healthy children five years and older with CAP who are not ill enough to require hospitalization, M. pneumoniae and C. pneumoniae are the most likely pathogens. A macrolide is the empirical treatment of choice for typical bacterial pneumonia in otherwise healthy children > 5 years old being treated in outpatient setting. Among the macrolide antibiotics, clarithromycin and azithromycin have a more convenient dosing schedule and fewer side effects than erythromycin, but erythromycin is less expensive. Macrolide antibiotics may provide coverage for S. pneumoniae, which is the most frequent typical bacterial pathogen for all age groups. However, approximately 40 to 50 percent of S. pneumoniae isolates are resistant to macrolides. Failure to respond to macrolide therapy may indicate the development of a complication, a macrolide-resistant pathogen, or the need to alter therapy to provide better pneumococcal coverage. Given the significant resistance of S. pneumoniae to macrolides, fluoroquinolones (e.g., levofloxacin, moxifloxacin) are another reasonable alternative for the outpatient treatment of CAP. In addition to their excellent Gram-negative spectrum, the fluoroquinolones are active against a number of the pathogens responsible for CAP, including beta-lactam-susceptible and non-susceptible S. pneumoniae, M. pneumoniae, and C. pneumoniae. However, S. pneumoniae resistant to levofloxacin has been identified.



Ampicillin (B) is used in neonatal infections. Cefotaxime (C) is an intravenous, third-generation cephalosporin used for inpatient treatment of community-acquired pneumonia for children with non-type-1 hypersensitivity reactions to penicillin. As the child is not hypoxemic, in respiratory distress, or toxic-appearing, she does not require inpatient treatment of her pneumonia at this time. A third-generation cephalosporin should also be used in the setting of confirmed beta-lactamase positive bacteria, such as Haemophilus influenzae or Moraxella catarrhalis or in the setting of complicated pneumonia without an identified pathogen. Clindamycin (D) may be used for treatment of typical bacterial pneumonias for children with type-1-hypersensitivity reactions to penicillin or for children with suspected aspiration pneumonia. Aspiration pneumonia typically involves the right middle or lower lobes and is more common in children with swallow dysfunction, such as those with static encephalopathy.
Correct Answer ( A )
Explanation:

Malaria is a mosquito-borne infection that is potentially fatal. The infection is caused by the Plasmodium protozoa and is transmitted by an infected female Anopheles mosquito. Cases of malaria in the United States are seen in patients who have traveled to malaria-endemic countries. Malaria is most prevalent in rural regions of countries with tropical climates. Patients planning a trip to a malaria-endemic region should be advised to take malaria prophylaxis to prevent infection. Clinical presentation includes several fever spikes per day, headache, cough, malaise, arthralgia, myalgia, chills and sweats. Diagnosis is made when the parasite is seen on blood smear with light microscopy. Regions where chloroquine-sensitive malaria is found include Haiti, the Dominican Republic, and certain parts of Central America. When infection with chloroquine-sensitive malaria is likely, treatment with the antimalarial agent chloroquine should be administered.



Doxycycline (B) is a tetracycline antibiotic used in the treatment of Lyme disease and Rocky Mountain spotted fever, both tick-borne illnesses. Isoniazid (C) is used as part of the treatment regimen for tuberculosis. Supportive care (D) is used to treat yellow fever and dengue fever, which are both mosquito-borne illnesses. Patients with malaria should be treated with supportive care to help with symptoms, but should also undergo a treatment regimen based on country visited and potential for chloroquine resistance.
Correct Answer ( C )
Explanation:

Shigella species are aerobic, gram-negative bacilli that are primarily transmitted person to person by the fecal-oral route or by ingestion of contaminated food or water. Children in daycare settings or crowded living conditions are most commonly affected. The onset of illness is several days after ingestion. Shigella infects the large intestine and causes watery or loose stools, fever, abdominal cramps or tenderness, tenesmus, and mucoid bloody stools. The characteristic bloody diarrhea appears after the fever subsides. Children under 2 years of age are more likely to develop high fever and seizures. Lab findings are notable for an increased number of bands on the CBC regardless of the actual white blood cell count. Due to high resistance to ampicillin and trimethoprim-sulfamethoxazole, azithromycin is the oral drug of choice for treatment in children. Rare complications include bacteremia, Reiter syndrome, hemolytic-uremic syndrome, toxic megacolon, intestinal perforation and toxic encephalopathy.



Salmonella (B) is the most commonly implicated pathogen in food-borne gastroenteritis and usually causes a self-limiting disease but rarely can lead to complications including bacteremia, enterocolitis, meningitis, and osteomyelitis. Campylobacter (A) infections cause diarrhea, abdominal pain mimicking appendicitis or intussusception, malaise and fever but in neonates and young infants bloody diarrhea without fever may be the only manifestation. Yersinia (D) usually manifests as fever and diarrhea in young children and stool often contains leukocytes, blood and mucus. Seizures are not associated with Yersinia.
Correct Answer ( C )
Explanation:

Scrotal mass and pain are common complaints in the primary care office. Etiologies range from incidental benign conditions to serious cancers to surgical emergencies. Any patient reporting scrotal swelling needs to be evaluated immediately. A careful history and physical examination, including transillumination, is necessary. The evaluation begins with determining which structure is swollen: skin, epididymis, testicle or spermatic cord. Dilation of the pampiniform venous plexus along the spermatic cord is referred to as varicocele. This condition is suspected in any swelling of the spermatic cord, especially when palpation reveals a nontender "bag of worms" consistency. There are primary and secondary types of varicocele. Primary varicocele is usually idiopathic in nature. Secondary varicocele can occur due to abdominal mass compression of the renal veins (more common with right sided varicocele), or superior mesenteric artery compression of the left renal vein (aka "Nutcracker Syndrome"; most commonly due to renal cell carcinoma and retroperitoneal fibrosis/adhesions). Patients with varicocele usually complain of scrotal heaviness and a "dragging" aching pain. It mostly occurs in tall, thin men between the ages of 15 and 30 years, and affects the left side more than the right. The "wormy" mass or swelling typically reduces when the patient is supine. Varicoceles, although not life threatening may cause decreased testicular artery flow and infertility, and therefore should be evaluated further with ultrasonography and possibly abdominal imaging.



Colonic (A and B) and bladder (D) masses are unlikely to cause venous compression and subsequent varicocele.
Correct Answer ( B )
Explanation:

Fluoride is highly beneficial in primary and secondary prevention of dental decay. It is incorporated into tooth enamel and also helps incorporate calcium and phosphate into enamel. While insufficient fluoride intake can increase the risk of dental caries, too much fluoride can result in fluorosis. Fluorosis can result from systemic fluoride consumption >0.05 mg/kg/day during enamel formation. This high fluoride consumption can be caused by residing in an area of high fluoride content in the drinking water (>2.0 ppm), swallowing excessive fluoridated toothpaste, or inappropriate fluoride prescriptions. Excessive fluoride during enamel formation affects ameloblastic function, resulting in inconspicuous white, lacy patches on the enamel to severe brownish discoloration and hypoplasia. Therefore, topical fluoride through low levels in water and toothpaste is favored to systemic fluoride through drops and tablets.



Community water fluoridation is considered a highly successful public health achievement. The US Department of Health and Human Services recently updated their optimal fluoride concentration recommendation from 1 ppm to 0.7 ppm (A) to account for the fluoride exposure from other sources. Fluorosis can occur at levels >2.0 ppm. Fluoride gel and varnish (C) are very effective in preventing caries as they leave a fluoride-calcium compound on tooth enamel that releases fluoride when the pH decreases from plaque. Varnish is preferred over gel as it adheres better to the teeth and requires little training to be applied. Starting in the first year of life, fluoride varnish should be applied to the teeth of children twice yearly. Toothbrushing with fluoridated (1000 ppm) toothpaste (D) twice a day is recommended for proper hygiene. Fluoride remains in the saliva after brushing at low concentrations for two to six hours. Fluoride levels less than 1000 ppm in toothpaste do not consistently prevent caries.
Correct Answer ( A )
Explanation:

Acute angle-closure glaucoma is an ophthalmologic emergency due to a closed anterior chamber angle. This is the only type of glaucoma that is curable. Patients present with acute onset of pain and vision loss that is most commonly unilateral. As intraocular pressure rises, patients may experience headache, nausea, vomiting, and abdominal pain that is sometimes mistaken as an acute abdominal process. The eye exam may reveal a red, tender globe that may be firm to touch. The cornea may be steamy or hazy and the pupil is mid-dilated and nonreactive. An ophthalmologic consult should be obtained immediately. Treatment incudes topical drops such as carbonic anhydrase inhibitors and beta-blockers. Permanent vision loss can occur if treatment is delayed.






Acute anterior uveitis (B) presents with a sudden onset of unilateral eye redness, photophobia, pain and lacrimation. It is associated with systemic illnesses including anklosing spondylitis, Crohn's, ulcerative colitis, reactive arthritis and sarcoidosis. Bacterial conjunctivitis (C) is a self-limiting condition that is characterized by acute onset of redness in one or both eyes, a gritty or burning sensation and discharge that begins watery and eventually becomes purulent. Many patients awaken with their eyelids stuck together. Treatment consists of antibiotic eye drops or ointments. A hyphema (D) is usually secondary to globe trauma and is caused by hemorrhage from either the ciliary body or the anterior chamber.
Correct Answer ( A )
Explanation:

Irritable bowel syndrome is considered an intestinal motility disorder in which chronic diarrhea is the main symptom. Associated symptoms include abdominal pain, bloating, flatulence and constipation. Some dysmotility causes include improper secretion due to luminal or environmental stimuli, decreased pain thresholds (hence, increased pain sensitivity) and dysregulation of the brain-intestinal axis. Rome III diagnostic criteria are based on symptom presence on >3 days per month over the past 3 months plus 2 or more of the following: defecation decreases symptoms, a change in the frequency of stooling or a change in the shape of stool. Treatment regimens are geared toward which of the symptoms a patient with irritable bowel syndrome suffers from most: pain, diarrhea, bloating or constipation. The pain associated with irritable bowel syndrome can be treated with selective-serotonin reuptake inhibitors like citalopram, tricyclic antidepressants like desipramine, and antispasmodics such as atropine, hyoscyamine, dicyclomine or scopolamine.



Loperamide (B), a opioid piperidine-derivative, is used to treat diarrhea, not pain, associated with irritable bowel syndrome. Lubiprostone (C) is a prostaglandin E1 derivative. Its chloride channel agonism is used in treating the constipation, not pain, associated with irritable bowel syndrome. Bloating and flatulence that are associated with irritable bowel syndrome can be treated with rifaximin (D), a semisynthetic antibiotic.
Correct Answer ( C )
Explanation:

Cor pulmonale is defined as an alteration in the structure and function of the right ventricle caused by a primary disorder of the respiratory system. Although the most common cause of right heart failure is left-sided heart disease, cor pulmonale is right heart dysfunction due to a lung, and not heart, problem. Just like systemic hypertension causes changes in left ventricular function, pulmonary hypertension causes changes in right ventricular function. This major underlying pathology is largely due to some kind of pulmonary vascular bed compromise, which can be primary pulmonary hypertension or thromboembolic disease, but more commonly anatomic compromise (COPD, interstitial lung disease and rheumatologic or connective tissue/collagen vascular disorders) or vasoconstrictive compromise (chronic hypoxic states and acidemia). When evaluating a patient with right heart failure, cor pulmonale is considered if pulmonary pathology is causative. However, if the etiologic evaluation is void of a pulmonary source, then the diagnosis of cor pulmonale cannot be made. In this situation, the clinician then tries to pinpoint a cardiac or blood disorder. Even when a pulmonary source is found to be a cause of right side heart failure, it is equally important to determine if there is such a coexisting non-pulmonary cause, such as increased blood viscosity, atrial and ventricular defects, congenital heart disease, cardiomyopathies and constrictive pericarditis. The general approach to evaluating a patient with suspected cor pulmonale begins with routine lab testing, chest radiography and electrocardiography (ECG). Further investigation of underlying pulmonary pathology is then accomplished via pulmonary function testing, ventilation/perfusion (V/Q) scanning and chest computed tomography. Right heart catheterization is the most accurate but invasive test to confirm the diagnosis of cor pulmonale.



Cardiac magnetic resonance imaging (A) may provide valuable information about right ventricular size, shape, structure and function. This information, however, does not identify the lung as the site of pathology. ECG (B) changes of right ventricular hypertrophy and strain may suggest cor pulmonale. Again, these do not isolate the location of the underlying pathology. Ultrafast ECG-gated computed tomography (D) is used to study right ventricular function, mainly ejection fraction and wall mass. Its use is still experimental, but in the future, it may be used in following the progression of, not diagnosing the presence of, cor pulmonale.
Correct Answer ( B )
Explanation:

Prolonged eustachian tube dysfunction is the most common cause of cholesteatoma formation, as the negative middle ear pressure draws the upper, flaccid portion of the tympanic membrane inward. The result is the formation of a squamous epithelium-filled sac which can fill with desquamated keratin and cause chronic infection. Cholesteatomas pose a significant danger to patients as they can eventually erode through the mastoid bone and destroy the ossicular chain. The inner ear and facial nerve may also become eroded, and intracranial involvement occasionally occurs. Because of the risk of devastating erosion, all patients with cholesteatomas should be referred to ENT for surgical marsupialization of the sac or its complete removal. Removal of the cholesteatoma may take precedence over preserving auditory function. Cholesteatomas should be suspected in patients with chronic mild otalgia, hearing loss, or chronic ear fullness, particularly with a long history of eustachian tube dysfunction.



Diabetes mellitus (A) is not a risk factor for cholesteatoma formation. It is a risk factor for malignant otitis externa, which may cause infectious osteomyelitis to spread from the floor of the ear canal to other regions of the ear and skull. Recent upper respiratory infections (C) are unlikely to cause a cholesteatoma. They may, however, contribute to development of acute otitis media. Recent water exposure (D) does not contribute to cholesteatoma formation. It is more likely to cause acute otitis externa.
Correct Answer ( B )
Explanation:

This patient's presentation is highly suggestive of mesenteric ischemia, which is best diagnosed by CT angiogram. Once ischemia has progressed to infarction, mortality climbs to 70% underscoring the need for rapid diagnosis and management. Mesenteric arterial embolism is the most common cause of mesenteric ischemia. Risk factors for arterial embolus include coronary artery disease, valvular heart disease and arrhythmias - particularly atrial fibrillation. The classic presentation of mesenteric ischemia is that of an elderly patient who presents with intermittent abdominal pain that is increased with eating. The pain is out of proportion to examination (meaning that the patient complains of severe pain but the exam reveals mild to moderate tenderness and may lack peritoneal signs). Additionally, patients will often have guaiac positive stool testing especially as the bowel becomes more ischemic. An elevated lactate level is also highly suggestive of mesenteric ischemia and has a high sensitivity. Because of the high morbidity and mortality associated with this disease, early surgical consultation and definitive imaging is central to management. The study of choice is either conventional angiography or CT angiography (more easily accessible). Management focuses on aggressive resuscitation, supportive care and early diagnosis.



Abdominal radiographs (A) are useful in eliminating other possible diagnoses including small bowel obstruction and bowel perforation but they are not sensitive in diagnosing either of these diseases or mesenteric ischemia. Angiography or CT angiogram should not be delayed while obtaining plain radiographs. Traditional CT scan of the abdomen and pelvis either with or without contrast (C) may show signs of ischemia like bowel wall edema or intramural gas but will not show where the vascular obstruction lies and is not sensitive for detecting mesenteric ischemia. A right upper quadrant ultrasound (D) is the diagnostic modality of choice for biliary disease (cholelithiasis, cholecystitis etc.) but has not been shown to be useful in diagnosing mesenteric ischemia.
Correct Answer ( D )
Explanation:

The patient's ECG is suggestive of Brugada syndrome. Brugada syndrome is a hereditary condition that leads to abnormal myocardial depolarization and predisposes otherwise young healthy individuals to ventricular fibrillation and sudden cardiac death. Several variants of Brugada syndrome exist, which involve mutations in the genes responsible for transmembrane sodium, calcium, and potassium ion channels in the heart. The incidence of Brugada syndrome is highest in Asian populations and is lower in groups originating from Western Europe. Most patients with Brugada syndrome are asymptomatic, and the disorder is identified incidentally via an abnormal ECG. Palpitations, near-syncope, and syncope may be reported. There may also be a family history of sudden cardiac death. Classic ECG findings of Type 1 Brugada syndrome include coved ST segment elevation followed by an inverted T wave in leads V1 to V3. If Brugada syndrome is suspected based on ECG findings or clinical history, patients should be referred to cardiology for further testing to rule out structural heart problems and confirm the diagnosis of Brugada syndrome. Medications with sodium channel blockade, such as flecainide and procainamide, should be avoided. The definitive treatment for Brugada syndrome is placement of an implantable cardioverter defibrillator device.



Atrial fibrillation (A) is not associated with Brugada syndrome. Eisenmenger's syndrome (B) occurs when a left-to-right cardiac shunt, such as from a ventricular septal defect, switches direction to become a right-to-left cardiac shunt. Type 2 second-degree heart block (C) is not associated with Brugada syndrome.
Correct Answer ( B )
Explanation:

Lactose breath hydrogen test will show a rise in breath hydrogen >20 ppm within 90 min of ingestion of 50 g of lactose and is positive for lactase deficiency. This test is positive in 90% of patients with lactose malabsorption. Common causes of false-negative results are recent use of oral antibiotics or recent high colonic enema. The diagnosis can usually be made on the basis of the history and improvement with dietary manipulation. Lactose intolerance is a prototypical carbohydrate malabsorption disorder. Individuals with the condition may experience diarrhea, cramps, abdominal pain, and flatus following ingestion of milk products. Symptom severity depends on the amount of lactose ingested and the fat content of the product (ie skim milk empties from the stomach faster, causing more symptoms). Diagnostic workup may include confirming the diagnosis with hydrogen breath test and excluding other conditions listed in the differential diagnosis that may also coexist with lactase deficiency. Imaging studies are generally not indicated. A small bowel series may be useful in patients with significant malabsorption. Nearly 50 million people in the United States have partial or complete lactose intolerance. There are racial differences, with <25% of white adults being lactose intolerant but >85% of Asian Americans and >60% of African Americans having some form of lactose intolerance.



Anti-Gliadin antibodies (A) are used in the diagnosis of celiac disease and not associated with lactose intolerance. Sweat test (C) is associated with the diagnosis of cystic fibrosis and urea breath test (D) is used to confirm eradication of H. Pylori infection.
Correct Answer ( A )
Explanation:

Based on the latest NCEP ATP III guidelines, the target LDL cholesterol in high-risk patients with a history of diabetes and coronary disease is < 100 mg/dL. Additionally, when a high-risk patient has low HDL-cholesterol or high triglyceride levels, the combination of niacin or a fibrate with an LDL-lowering drug should be considered. However, regardless of the drug regimen employed, patients with diabetes should maintain tight glycemic control, which in itself can help reverse the dyslipidemic profile that is prevalent in diabetics. As with all patients, lifestyle modification, including weight reduction and regular exercise, remains an important cornerstone of the treatment of dyslipidemia in patients with diabetes. The importance of dyslipidemia as a contributor to cardiovascular risk in patients with diabetes is reflected in the new guidelines of the NCEP ATP III. For the first time, diabetes is considered a coronary heart disease (CHD) risk equivalent, meaning that patients with diabetes have a risk of CHD that is similar to that of patients with clinically manifest CHD (> 20% risk of an event in the following 10 years). In addition, the presence of multiple CHD risk factors, the metabolic syndrome, and mixed hyperlipidemia (high triglyceride and low HDL-cholesterol levels) should be taken into account when estimating a patient's global risk.

An LDL of < 160 (C) is never a goal of a diabetic patient. According to the NCEP ATP III guidelines, diabetic patients are candidates for cholesterol-lowering therapy if the LDL-cholesterol level is higher 130 (B). Reducing LDL cholesterol to less than 70 (D) is no longer the goal for a diabetic patient.
Correct Answer ( B )
Explanation:

Doxycycline 100 mg oral tablet twice per day for twenty-one days is the correct treatment and dosing for the suspected diagnosis of Lyme disease with a known erythema migrans (bulls-eye) rash. Lyme disease is caused by the spirochete Borrielia burgdorferi. It is transmitted to humans through a tick bite. The disease is most common in the northeastern United States, with Connecticut having one of the highest prevalence rates. It is recommended to treat any patient with suspected Lyme disease with an associated erythema migrans rash.


Ceftriaxone 250 mg single dose intramuscular injection (A) is the correct treatment for urethritis caused by Neisseria gonorrhoeae. Gonococcal urethritis typically presents with painful urethral discharge. Patient's with urethritis should be treated concurrently for Chlamydial infection since the two infections commonly occur together. Metronidazole 2 g single dose orally (C) is the treatment for a trichamonal infection. Trichamonas is a flagellated protozoan, which infects the genitourinary tact of males and the lower urinary tract of females. Associated clinical findings include a malodorous, frothy, yellow-green discharge and a wet-mount that reveals motile flagellates. Watch and wait (D) is not the treatment of choice. Though it is suggested to send blood work for a confirmatory laboratory titer, the proper treatment course is to treat any patients with symptoms suggestive of Lyme disease. Delayed treatment can result in central nervous system and cardiac complications such as Bells' palsy, encephalitis, pericarditis, and heart block.
Correct Answer ( D )
Explanation:

Weak plantarflexion of the foot is a physical examination finding specific for an L5-S1 herniated nucleus pulposus. A herniated nucleus pulposus, also known as a herniated disc, occurs when there is a weakness in the outer annulus fibrosus and the inner nucleus pulposus herniates outward through the small tears. If not corrected, the nucleus pulposus continues to push outward causing impingement on the spinal nerves resulting in radiculopathy, or disease of a nerve. When a disc herniation occurs between the L5 and S1 vertebra, an S1 radiculopathy occurs resulting in pain radiating down the posterior aspect of the leg and foot along with weakness with plantarflexion due to weakness of the gastrocnemius muscle. The ankle reflex is also typically lost. Diagnosis is formulated through physical examination findings as well as confirmation from imaging. Treatment includes pain medications, physical therapy, and surgical interventions, such as a discectomy to remove the herniated nucleus pulposus from the impinged nerve.



Decreased lateral leg sensation (A) is a finding of a nerve impingement at the L4-L5 level. An L5 nerve root impingement is one of the most common sites of radiculopathy of the spine. Patients present with low back pain that radiates down the lateral aspect of their leg and foot and can result in foot drop or decreased strength of foot dorsiflexion. Reflexes are typically spared with an L5 radiculopathy. Weak dorsiflexion of the foot (C) is a result of a herniated nucleus pulposus between L4 and L5. At this level, an L5 radiculopathy causes weakness in foot dorsiflexion, inversion, eversion, and toe extension. Weakness of the foot dorsiflexors results in foot drop because the patient can't lift the foot up. Urinary incontinence (B) is an alarming sign of sacral radiculopathy that is known as cauda equina syndrome. This is a rare, but emergent process in which extreme pressure or swelling compresses the nerve roots intrathecally. Nerves may be compressed at a higher level within the lumbar spine, but the amount of pressure causes symptoms of decreased perineal sensation, as well as urinary and bowel incontinence and sexual dysfunction. This is a life-threatening emergency, and treatment includes emergent decompression of the impinged nerves.
Correct Answer ( C )
Explanation:

This patient presents with symptoms consistent with measles requiring supportive care. Measles is a highly contagious viral illness spread by infectious droplets. The incubation period for the virus is 10-14 days and patients are contagious 2 days prior to the onset of symptoms to 4 days after the rash appears. The rash is typically preceded by fever, which increases daily for 5-6 days, and malaise. Cough, coryza and conjunctivitis begin about 24 hours after the onset of fever. Koplik's spots, a pathognomonic finding, appear on the second day of illness. They are small, bright red spots with blue-white centers appearing the buccal mucosa. Rash follows on the fourth to fifth day of the illness. The rash is characterized by maculopapular lesions beginning on the forehead and face and spreading to the trunk, arms and legs. Treatment for measles focuses on supportive care and recognition of bacterial complications. Isolation of infected patients is usually not helpful as exposure usually occurs prior to identification of the disease. Additionally, patients are not contagious after the rash has been present for 5 days. Administration of human immune serum globulin (ISG) can modify the course of disease if given within 6 days of exposure. Live measles virus vaccine may prevent measles if given within 72 hours of exposure.



Ceftriaxone (A) may be helpful if a post-measels bacterial pneumonia is suspected. Otherwise, it does not play a role in treatment. Isolation (B) is likely to be unhelpful, as the family has already been exposed during the infectious period. Tetracycline (D) is the treatment of choice for Rocky Mountain spotted fever which is characterized by a rash, which spreads from extremities centrally.
Correct Answer ( A )
Explanation:

Acromegaly usually has an insidious onset, with a time to diagnosis on the order of 6-10 years. The classic facial findings, which include enlargement of the supraorbital ridges, mandible and a widened nose, are sometimes difficult to identify without a reference to the patient's appearance from several years earlier. Patients with this condition sometimes present with nonspecific symptoms such as arthralgias, fatigue, and headache. More specific complaints such as visual field defects or increasing ring and shoe sizes should prompt a physician to consider this diagnosis. The condition is caused by a growth hormone-secreting pituitary adenoma in 98% of cases. In younger patients this disease results in gigantism. Blood testing for growth hormone and IGF-1 is usually adequate for initial testing. Because of the relatively high incidence of nonfunctioning, incidentally discovered pituitary adenomas, imaging studies should be obtained only after a firm biochemical diagnosis of acromegaly has been made. The sella turcica should be imaged first, since GH-secreting pituitary adenoma is the most common cause of acromegaly. Magnetic resonance imaging is the imaging study of choice. For pituitary adenomas, transsphenoidal surgery is usually considered the first line of treatment, followed by medical therapy for residual disease. Somatostatin and dopamine analogues and growth hormone receptor antagonists are the mainstays of medical treatment for growth hormone excess after surgery.



Clinical findings in Cushing's disease (B) include weight gain, truncal obesity, striae, hypertension, glucose intolerance and infections. The pituitary tumors in Cushing's disease are usually microadenomas, which, by definition, are 10 mm or less in diameter. These tumors are most often discovered when clinical manifestations from hypersecretion of ACTH prompt an appropriate diagnostic work-up. The classic clinical presentation of scleroderma (D) is a young or middle-age woman with Raynaud phenomenon and skin changes accompanied by musculoskeletal discomfort and gastrointestinal symptoms. Polymyalgia rheumatica (C), the most common chronic inflammatory condition in older adults, primarily affects proximal muscles and joints, causing disability. Proximal myalgias and arthralgias typically develop over weeks to months, worsening at night and with movement. True muscle weakness, as opposed to limited effort because of pain or atrophy from disuse, is not associated with pure polymyalgia rheumatica.
Correct Answer ( A )
Explanation:

In the United States, prostate cancer is the most frequently diagnosed type of cancer in men after skin cancer. Prostate cancer is seen more commonly in African-American men and the likelihood of developing this type of cancer increases with age. It is uncommon in men younger than 50 years of age. Risk factors include a family history of prostate cancer, cigarette smoking and a diet high in animal fat. Most patients diagnosed with prostate cancer are asymptomatic and the cancer is found on digital rectal exam (DRE) or because of an elevated serum prostate specific antigen (PSA). A physical exam finding of asymmetric areas of induration or nodules on DRE is suspicious for prostate cancer and further workup should be initiated. Diagnosis is made with biopsy. Treatment decisions are determined after discussion with the patient about the severity of disease and quality of life related to treatment side effects. Treatment options include active surveillance, prostatectomy, radiation therapy and hormonal therapy.



Elevated serum prostate specific antigen (B) and the presence of hematuria on urinalysis (C) may be seen in both prostate cancer and benign prostatic hyperplasia (BPH). Physical exam findings help to differentiate between the two conditions. The diagnostic approach to patients with suspected BPH includes complete history, physical exam, urinalysis, serum PSA and creatinine, and evaluation for urinary obstruction. Symmetric enlargement and firmness of the prostate on DRE (D) is a physical finding seen in patients with BPH.
Correct Answer ( C )
Explanation:

The patient has a posterior epidural abscess with adjacent osteomyelitis and myositis. The most common cause of an epidural abscess is hematogenous spread of infection, not direct extension from skin or soft tissue infection. Major risk factors include diabetes, intravenous drug abuse, chronic renal failure, alcoholism, and immunosuppression. The most common organism involved is Staphylococcus aureus. Other organisms include streptococci, anaerobes, gram-negative bacilli, and Pseudomonas aeruginosa. Patients present with localized back pain with tenderness to percussion. Fevers are common (reported in up to 75% of patients). MRI is the diagnostic modality of choice, but erythrocyte sedimentation rate is a sensitive marker and may be used in conjunction with plain radiographs to screen for infectious spinal disease.



Vancomycin is an important component of the antibiotic regimen because it covers methicillin-resistant Staphylococcus aureus (MRSA) and is usually combined with a 3rd-generation cephalosporin (A). Cefepime is a 4th-generation cephalosporin with pseudomonas coverage. Metronidazole or clindamycin can be added for anaerobic coverage. While the classic triad consists of back pain, fever, and neurologic deficits (D), only a small proportion of patients actually have all three components at presentation. The most common cause of an epidural abscess is hematogenous spread of infection, not direct extension from skin or soft tissue infection (B).
Correct Answer ( C )
Explanation:

Polymyositis is an inflammatory myopathy that is classified by patient age at onset or by coexisting diseases, such as myositis associated with neoplasia or myositis associated with collagen vascular diseases (e.g., systemic scleroderma, systemic lupus erythematous). They have a bimodal distribution and are seen most often between age 10 to 15 and 45 to 60 years. Myositis is most common after age 50. The cause of inflammatory myopathies is unknown, but evidence suggests a genetic predisposition (associated with certain HLA markers) combined with an environmental insult, such as viruses, thereby initiating an autoimmune process. Patients usually experience progressive, symmetric, proximal muscle weakness with fatigue, malaise, and morning stiffness. Muscles often affected are those of the shoulder, neck, and pelvic girdle. Pulmonary (interstitial pneumonitis or fibrosis), cardiac (cardiomyopathy, congestive heart failure, arrhythmias), pharyngeal (dysphagia), and musculoskeletal (myalgias, arthralgias) symptoms might occur, although most patients do not experience synovitis. CK as well as aldolase, ALT, AST, and lactate dehydrogenase (LDH) levels might be elevated. ESR is elevated only half the time. Muscle biopsy can also be helpful in diagnosis. Prednisone, 1 mg/kg/day for up to several months, is the drug of choice; the earlier started in the disease process, the more effective it is. If prednisone is not sufficient, methotrexate, azathioprine, or another immunosuppressant is added.



Antibiotics (A), NSAIDs (B) and radiation treatment (D) are not recommended in the primary treatment of polymyositis.
One Step Further
Correct Answer ( D )
Explanation:

This patient has an acute myocardial infarction (MI). An acute MI is clinically characterized by left-sided, substernal, chest pain (often described as an "elephant on my chest," tightness, or pressure rather than pain itself) that radiates down the left arm or left jaw, diaphoresis, nausea/vomiting, and shortness of breath. These symptoms are a result of myocardial death due to coronary vessel occlusion or vasospasm, often as a result of rupture of an atherosclerotic plaque. The definition of an acute MI, as described by the European Society for Cardiology and American College of Cardiology (ACC) is a rise and fall of a cardiac biomarker (troponin) in addition to clinical symptoms, ECG changes, or coronary artery changes as noted on an interventional level. Risk factors for an acute MI include hypertension, hypercholesterolemia, diabetes, tobacco, male, increased age, and family history. This patient has ST-segment changes in leads II, III, and aVF, correlating to an inferior wall MI. In a patient with an acute MI, the first step in management is to place the patient on a cardiac monitor to recognize any dysrhythmias, establish a peripheral IV, give oxygen if hypoxic, and administer aspirin.

An ischemic right ventricle becomes preload dependent because it can no longer pump blood to the left side of the heart. Administering nitroglycerin (C) (a preload reducer) to a patient having ischemia of the right ventricle can lead to severe hypotension. Because the right coronary artery often supplies the inferior aspect of the heart and the right ventricle, whenever there is evidence of ST-segment elevation in the inferior leads (II, III, aVF), it is important to exclude a right ventricular infarct by obtaining "right-sided leads." This is performed by placing the precordial leads on the right side of the patient's chest instead of the left. Lead rV4 is thought to be the most sensitive in identifying a right ventricular infarct. Similarly, labs, including serial cardiac biomarkers (troponin) should be drawn; however, this is not the most appropriate next step. It is important to notify the cath lab (B) of the patient's need for percutaneous intervention, but the first priority are the ABCs and administering an aspirin. The cath lab should be notified immediately after this is performed. Although a stress test (A) would be useful in a patient with cardiac risk factors, this patient has active cardiac symptoms and the ACC/AHA guidelines recommend such testing be performed when patients are free of ischemic or heart failure symptoms for at least 8-12 hours. In addition, this patient has evidence for a STEMI and should undergo percutaneous intervention in the cath lab.
Correct Answer ( A )
Explanation:

Coxsackie A 16, an enterovirus, is the most frequent cause of Hand-Foot-and-Mouth disease (H-F-M). Hand, foot, mouth disease is characterized by several days of fever (often high and acute in onset), irritability, and decreased appetite. On physical exam, the oropharynx is inflamed with vesicles that can be present on the tongue, buccal mucosa, lips, palate, posterior pharynx and gingiva which can ulcerate leaving 4-5 mm shallow lesions with surrounding erythema. Lesions typically resolve in about one week. Its distinctive presentation also includes a vesiculopapular skin rash typically on the dorsum of the hands and feet but may also present on the palms and soles and buttocks and groin. The skin lesions are usually tender and approximately 3-7 mm in size. Complications are rare but include myocarditis and pericarditis. Treatment is supportive with cool fluids and pain relievers to prevent dehydration from poor oral intake due to pain.



Herpes gingivostomatitis is an acute oropharyngeal infection and is the most common presentation of primary herpes simplex virus 1 (B) infection in children six months to five years. It is sudden in onset and is associated with high fever, mouth pain, drooling, and food and drink refusal. The gums become swollen and vesicles develop throughout the oral cavity and are usually more extensive than that of those with H-F-M and are limited to the anterior oral cavity unlike the posterior involvement of coxsackie. There is no skin rash associated with herpes simplex virus 1 infection. Human herpes virus 6 (C) is associated with roseola infantum (sixth disease). This self-limited disease occurs in infancy and early childhood. It begins with the abrupt onset of high fever usually lasting 72 hours. Upon defervescence, a 2-3 mm morbilliform rash develops on the trunk. Varicella zoster virus (D) is associated with both varicella (chicken pox) and zoster (shingles). Varicella is associated with skin lesions that typically present first on the scalp and face and spread downward to the trunk. They are pruritic and evolve from erythematous macules to papules to form a clear, fluid filled vesicle. This occurs over a 24-48 hour period then lesions begin to crust over as new vesicles are appearing. Zoster is associated with a vesicular rash in a dermatomal distribution.
Correct Answer ( D )
Explanation:

Polycystic ovarian syndrome (PCOS) is characterized by androgen excess, insulin resistance, and gonadotropin abnormalities. PCOS is the most frequent cause of anovulatory infertility. The diagnostic criteria for PCOS are chronic anovulation and hyperandrogenism (established by hormone measurements or clinical findings such as acne or hirsutism) in women whom secondary causes have been excluded. Polycystic appearing ovaries on ultrasound examination are a nonspecific finding in PCOS. Important factors in the physical examination include the following: the presence of acne, balding, or clitoromegaly; the distribution of body hair; enlargement of the ovaries (based on a pelvic examination); and signs of insulin resistance. Weight reduction is the first line treatment for polycystic ovarian syndrome for women who desire to conceive. As little as 5% total weight reduction has been shown to improve the metabolic and reproductive abnormalities in PCOS.



Clomiphene citrate (A) is the next line of treatment if weight loss does not lead to return of ovulation. Multiple studies have shown conflicting evidence comparing the efficacy of metformin and clomiphene for ovulation induction, however clomiphene remains the first line pharmacologic agent for ovulation induction in PCOS. Gonadotropin therapy (B) is used if clomiphene citrate fails. Low-dose gonadotropin therapy is recommended over high-dose therapy. Spironolactone (C) is the first-line agent to treat hirsutism in women with PCOS and has no role in ovulation induction. Combination oral contraceptives are also used to prevent hirsutism and menstrual abnormalities in patients whom do not wish to conceive, however they are not first-line.
Correct Answer ( A )
Explanation:

The pericardium is a two layered sac (visceral and parietal pericardia) which surrounds the heart and great vessels. It normally contains 15-50 ml of straw-colored fluid. The pericardium can become inflamed (pericarditis), or become filled with fluid (effusion) or become constrictive (as an end result of inflammation). Acute pericarditis is most commonly caused by an infectious etiology (mainly viral, but possibly bacterial, tuberculous or fungal) or unknown source (idiopathic, 80% of which self-resolve within 1-3 days). It can also arise from neoplastic, autoimmune, radiation or uremic insult. In addition, pericarditis can be associated with acute transmural myocardial infarction or proximal aortic dissection. Pericarditis is marked by pleuritic chest pain that is less with sitting forward and worse with recumbency, effusion and tamponade, and friction rub, a rough sound heard best at the left lateral sternal border with the diaphragm. Viral, bacterial, tuberculous and fungal sources are possible. ECG, echo, chest radiograph, CBC, ESR and serum troponins are the preferred initial diagnostic tests. Treatment includes NSAIDs, corticosteroids and colchicine. Drainage and antibiotics are usually necessary if an infectious etiology is found.



The pain of pericarditis is pleuritic; that is, it is worse with deep inspiration, not expiration (B). As effusion is common with pericarditis, an increase in pericardial sac volume can have a mass effect on surrounding tissue, namely the left posterior lung. This can lead to compressive atelectasis, decreased breath sounds (C) and dullness (D) to percussion (Ewart's sign).
Correct Answer ( D )
Explanation:

A patient being evaluated for preterm rupture of membranes should undergo a sterile speculum exam with pH testing of vaginal fluid and evaluation for ferning. Normal vaginal fluid is acidic (pH ranging between 3.5 to 6). Amniotic fluid is alkaline. Therefore a color change of nitrazine paper to blue, indicating a pH of > 6.5, signals the presence of amniotic fluid. Of note, blood and semen can cause false positive results. Ferning, a distinctive pattern of amniotic fluid as it crystallizes on a glass slide, also indicates the presence of amniotic fluid. Blood may obscure ferning, and mucus may cause a false positive result. The cervix should also be visually inspected for effacement and dilatation. Other clues to premature rupture of membranes include fluid pooling in the vagina as it leaks from the cervix. The patient may be asked to cough or Valsalva to see if this induces more leakage of fluid. If preterm rupture of membranes is suspected, obstetric consultants should be contacted. Women with preterm rupture of membranes usually progress to active labor. Preterm labor before 23 weeks gestation is associated with very high fetal mortality rates. Women between 24 and 36 weeks of gestation with preterm labor are candidates for tocolysis to prolong the pregnancy to allow continued time for fetal development. The decision to use tocolytics must be made by an obstetrician who can discuss risks and benefits with the patient. Antenatal administration of corticosteroids is indicated for women prior to 34 weeks gestation to speed fetal lung maturity and is associated with improved outcomes.



Microscopic evaluation of vaginal fluid revealing pseudohyphae (A) is characteristic of candidal yeast infection. Bloody vaginal secretions (B) may be suggestive of bloody show (loss of cervical mucous plug), but does not indicate preterm rupture of membranes unless the presence of amniotic fluid is confirmed. Vaginal epithelial cells with a stippled appearance on microscopic evaluation (C) is indicative of bacterial vaginosis.